2015 Molina Dual Options Drug Formulary
Transcription
FOR MU LA RY (List of Covered Drugs) 2015 Molina Dual Options Medicare-Medicaid Plan Version 14 UPDATED: 11/2015 Member Services (877) 901-8181, TTY/TDD 711 Monday - Friday, 8 a.m. - 8 p.m. local time H8046_15_16003_0002_MMPILRx Approved HPMS Approved Formulary File Submission 00015353 Version 14 Molina Dual Options 2015 List of Covered Drugs (Formulary) This is a list of drugs that members can get in Molina Dual Options. •• Molina Dual Options is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. •• Benefits, List of Covered Drugs, pharmacy and provider networks, and/or copayments may change from time to time throughout the year and on January 1 of each year. •• You can always check Molina Dual Options’ up-to-date List of Covered Drugs online at www.MolinaHealthcare.com/Duals. •• You can ask for this information in other formats, such as Braille or large print. Call (877) 901-8181. The call is free. •• Limitations, copays, and restrictions may apply. For more information, call Molina Dual Options Member Services or read the Molina Dual Options Member Handbook. •• Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. •• You can get this document in Spanish, or speak with someone about this information in other languages for free. Call (877) 901-8181. The call is free. •• Puede obtener este documento en español, o hablar con una persona acerca de esta información en otros idiomas gratuitamente. Llame al (877) 901-8181. Esta llamada es gratis. H8046_15_16003_0002_MMPILRx Approved 44088MMP1115 If you have questions, please call Molina Dual Options at (877) 901-8181, TTY/TDD 711, Monday - Friday, 8 a.m. – 8 p.m. local time. The call is free. For more information, visit www.MolinaHealthcare.com/Duals. i Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.) The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by Molina Dual Options. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.” → Molina Dual Options will cover all medically necessary drugs on the Drug List if: • your doctor or other prescriber says you need them to get better or stay healthy, and • you fill the prescription at a Molina Dual Options network pharmacy. → Molina Dual Options may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at www.MolinaHealthcare.com/Duals or call Member Services at (877) 901-8181, TTY/TDD: 711. 2. Does the Drug List ever change? Yes. Molina Dual Options may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: • a cheaper drug comes along that works as well as a drug on the Drug List now, or • we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: • Decide to require or not require prior approval for a drug. (Prior approval is permission from Molina Dual Options before you can get a drug.) • Add or change the amount of a drug you can get (called “quantity limits”). • Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page vii.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. → You can always check Molina Dual Options’ up to date Drug List online at www.MolinaHealthcare.com/Duals. You can also call Member Services to check the current Drug List at (877) 901-8181, TTY/TDD: 711. 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. This notification is received on your monthly pharmacy Explanation of Benefits (EOB). 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Please speak to your physician to find an alternative that is safe for you. ii If you have questions, please call Molina Dual Options at (877) 901-8181, TTY/TDD 711, Monday - Friday, 8 a.m. – 8 p.m. local time. The call is free. For more information, visit www.MolinaHealthcare.com/Duals. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example: • Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Molina Dual Options before you fill your prescription. If you don’t get approval, Molina Dual Options may not cover the drug. • Quantity limits: Sometimes Molina Dual Options limits the amount of a drug you can get. • Step therapy: Sometimes Molina Dual Options requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages 1-103. You can also get more information by visiting our web site at www.MolinaHealthcare.com/Duals. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an “exception” from these limits. Please see question 11 for more information on exceptions. → If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Molina Dual Options member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 1 has a column labeled “Necessary actions, restrictions, or limits on use.” 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: • You can search alphabetically (if you know how to spell the drug), or • You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it in the Index of Drugs. The Index of Drugs provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index of Drugs. Look in the Index of Drugs and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index of Drugs and find the name of your drug in the first column of the list. To search by medical condition, find the section labeled “List of drugs by medical condition” on page 1. Then find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions. If you have questions, please call Molina Dual Options at (877) 901-8181, TTY/TDD 711, Monday - Friday, 8 a.m. – 8 p.m. local time. The call is free. For more information, visit www.MolinaHealthcare.com/Duals. iii 9. What if the drug you want to take is not on the Drug List? If you don’t see your drug on the Drug List, call Member Services at (877) 901-8181, TTY/TDD: 711 and ask about it. If you learn that Molina Dual Options will not cover the drug, you can do one of these things: • Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or • You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. What if you are a new Molina Dual Options member and can’t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Molina Dual Options. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover a 30-day supply of your drug if: • you are taking a drug that is not on our Drug List, or • health plan rules do not let you get the amount ordered by your prescriber, or • the drug requires prior approval by Molina Dual Options, or • you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 91 days. You may refill the drug multiple times during the 90 days. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. Transition Policy New members in our Plan may be taking drugs that aren’t on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. See the Member Handbook to learn more about how to request an exception. Please contact Member Services if your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover or requesting a formulary exception. During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in our Plan for Part D drugs (tiers 1 and 2) and 90 days for your Medicaid drugs (tier 3). If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of the new plan year. When a member goes to a network pharmacy and we provide a temporary supply of a drug that isn’t on our formulary, or that has coverage restrictions or limits (but is otherwise considered a “Part D drug”), we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover. iv If you have questions, please call Molina Dual Options at (877) 901-8181, TTY/TDD 711, Monday - Friday, 8 a.m. – 8 p.m. local time. The call is free. For more information, visit www.MolinaHealthcare.com/Duals. If a new member is a resident of a long-term-care facility (like a nursing home), we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our Plan. If the resident has been enrolled in our Plan for more than 90 days and needs a drug that isn’t on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception. Exceptions are available in situations where you experience a change in the level of care you are receiving that also requires you to transition from one facility or treatment center to another. In such circumstances, you would be eligible for a temporary, one-time fill exception even if you are outside of the first 90 days as a member of the plan. 11. Can you ask for an exception to cover your drug? Yes. You can ask Molina Dual Options to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. • For example, Molina Dual Options may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. • Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber’s supporting statement. 13. How can you ask for an exception? To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). Molina Dual Options covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for “over-the-counter”. Molina Dual Options covers some OTC drugs when they are written as prescriptions by your provider. You can read the Molina Dual Options Drug List to see what OTC drugs are covered. 16. Does Molina Dual Options cover OTC non-drug products? Molina Dual Options covers some OTC drugs when they are written as prescriptions by your provider. You can read the Molina Dual Options Drug List to see what OTC non-drug products are covered. 17. What is your copay? You can read the Molina Dual Options Drug List to learn about the copay for each drug. Molina Dual Options members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. If you have questions, please call Molina Dual Options at (877) 901-8181, TTY/TDD 711, Monday - Friday, 8 a.m. – 8 p.m. local time. The call is free. For more information, visit www.MolinaHealthcare.com/Duals. v Copays are listed by tiers. Tiers are groups of drugs with the same copay. • Tier 1 drugs are generic drugs. The copay will be $0. • Tier 2 drugs are brand name drugs. The copay will be from $0 to $6.60, depending on your level of Medicaid eligibility. • Tier 3 drugs have a copay of $0. vi If you have questions, please call Molina Dual Options at (877) 901-8181, TTY/TDD 711, Monday - Friday, 8 a.m. – 8 p.m. local time. The call is free. For more information, visit www.MolinaHealthcare.com/Duals. List of Covered Drugs The list of covered drugs below gives you information about the drugs covered by Molina Dual Options. If you have trouble finding your drug in the list, turn to the Index that begins on page 104. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lower-case italics (e.g., simvistatin). The information in the necessary actions, restrictions, or limits on use column tells you if Molina Dual Options has any rules for covering your drug. Note: The (*) next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at (877) 901-8181, TTY/TDD: 711. You can also read the Member Handbook to learn how to appeal a decision. The information in the Requirements/Limits column tells you if Molina Dual Options has any special requirements for coverage of your drug. QL stands for Quantity Limits PA stands for Prior Authorization ST stands for Step Therapy Criteria OTC stands for Over the Counter B/D This drug may be covered under Medicare Part B or D depending upon the circumstances LA stands for Limited Access Drug NM stands for Not available through mail-order If you have questions, please call Molina Dual Options at (877) 901-8181, TTY/TDD 711, Monday - Friday, 8 a.m. – 8 p.m. local time. The call is free. For more information, visit www.MolinaHealthcare.com/Duals. vii viii If you have questions, please call Molina Dual Options at (877) 901-8181, TTY/TDD 711, Monday - Friday, 8 a.m. – 8 p.m. local time. The call is free. For more information, visit www.MolinaHealthcare.com/Duals. MOLINA_IL_MMP_CY15_2T_STANDARD eff 11/01/2015 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION GOUT - DRUGS TO TREAT GOUT allopurinol tab 100 mg allopurinol tab 300 mg colchicine w/ probenecid tab 0.5-500 mg COLCRYS TAB 0.6MG probenecid tab 500 mg ULORIC TAB 40MG ULORIC TAB 80MG $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0 (1) $0-$6.60 (2) $0-$6.60 (2) QL (120 tabs / 30 days) ST ST NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib cap 50 mg $0 (1) celecoxib cap 100 mg $0 (1) celecoxib cap 200 mg $0 (1) celecoxib cap 400 mg $0 (1) diclofenac potassium tab 50 mg $0 (1) diclofenac sodium tab delayed release 25 $0 (1) mg diclofenac sodium tab delayed release 50 $0 (1) mg diclofenac sodium tab delayed release 75 $0 (1) mg diclofenac sodium tab sr 24hr 100 mg $0 (1) diflunisal tab 500 mg $0 (1) etodolac cap 200 mg $0 (1) etodolac cap 300 mg $0 (1) etodolac tab 400 mg $0 (1) etodolac tab 500 mg $0 (1) etodolac tab sr 24hr 400 mg $0 (1) etodolac tab sr 24hr 500 mg $0 (1) etodolac tab sr 24hr 600 mg $0 (1) flurbiprofen tab 50 mg $0 (1) flurbiprofen tab 100 mg $0 (1) ibuprofen susp 100 mg/5ml $0 (1) ibuprofen tab 400 mg $0 (1) ibuprofen tab 600 mg $0 (1) ibuprofen tab 800 mg $0 (1) ketoprofen cap 50 mg $0 (1) ketoprofen cap 75 mg $0 (1) MELOXICAM SUSP 7.5 MG/5ML $0 (1) meloxicam tab 7.5 mg $0 (1) QL QL QL QL (60 (60 (60 (60 caps caps caps caps / / / / 30 30 30 30 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid days) days) days) days) 1 Drug Name (By Medical Condition) meloxicam tab 15 mg nabumetone tab 500 mg nabumetone tab 750 mg naproxen dr tab 375mg naproxen dr tab 500mg naproxen sodium tab 275 mg naproxen sodium tab 550 mg naproxen susp 125 mg/5ml naproxen tab 250 mg naproxen tab 375 mg naproxen tab 500 mg piroxicam cap 10 mg piroxicam cap 20 mg sulindac tab 150 mg sulindac tab 200 mg WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen w/ codeine soln 120-12 $0 mg/5ml acetaminophen w/ codeine tab 300-15 mg $0 acetaminophen w/ codeine tab 300-30 mg $0 acetaminophen w/ codeine tab 300-60 mg $0 butorphanol tartrate inj 1 mg/ml $0 butorphanol tartrate inj 2 mg/ml $0 hydrocodone-acetaminophen soln 7.5-325 $0 mg/15ml hydrocodone-acetaminophen tab 5-325 mg$0 hydrocodone-acetaminophen tab 7.5-325 $0 mg hydrocodone-acetaminophen tab 10-325 $0 mg hydrocodone-ibuprofen tab 7.5-200 mg $0 tramadol hcl tab 50 mg $0 tramadol-acetaminophen tab 37.5-325 mg $0 (1) QL (5000 mL / 30 days) (1) (1) (1) (1) (1) (1) QL (400 tabs / 30 days) QL (400 tabs / 30 days) QL (400 tabs / 30 days) (1) (1) QL (360 tabs / 30 days) QL (360 tabs / 30 days) (1) QL (360 tabs / 30 days) (1) (1) (1) QL (150 tabs / 30 days) QL (240 tabs / 30 days) QL (240 tabs / 30 days) QL (5400 mL / 30 days) OPIOID ANALGESICS, CII - DRUGS TO TREAT PAIN DURAMORPH INJ 0.5MG/ML DURAMORPH INJ 1MG/ML endocet tab 5-325mg endocet tab 7.5-325 endocet tab 10-325mg fentanyl citrate lozenge on a handle 200 mcg fentanyl citrate lozenge on a handle 400 mcg $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) B/D B/D QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (120 lozenges / 30 days), PA QL (120 lozenges / 30 days), PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 2 Drug Name (By Medical Condition) fentanyl mcg fentanyl mcg fentanyl mcg fentanyl mcg fentanyl citrate lozenge on a handle 600 WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) citrate lozenge on a handle 800 $0-$6.60 (2) citrate lozenge on a handle 1200 $0-$6.60 (2) citrate lozenge on a handle 1600 $0-$6.60 (2) td patch 72hr 12 mcg/hr $0 (1) fentanyl td patch 72hr 25 mcg/hr $0 (1) fentanyl td patch 72hr 50 mcg/hr $0 (1) fentanyl td patch 72hr 75 mcg/hr $0 (1) fentanyl td patch 72hr 100 mcg/hr $0 (1) FENTORA TAB 100MCG $0-$6.60 (2) FENTORA TAB 200MCG $0-$6.60 (2) FENTORA TAB 400MCG $0-$6.60 (2) FENTORA TAB 600MCG $0-$6.60 (2) FENTORA TAB 800MCG $0-$6.60 (2) hydromorphone hcl liqd 1 mg/ml $0 (1) hydromorphone hcl preservative free (pf) $0 (1) inj 10 mg/ml hydromorphone hcl tab 2 mg $0 (1) hydromorphone hcl tab 4 mg $0 (1) hydromorphone hcl tab 8 mg $0 (1) LAZANDA SPR 100MCG $0-$6.60 (2) LAZANDA SPR 400MCG $0-$6.60 (2) methadone con 10mg/ml methadone hcl soln 5 mg/5ml methadone hcl soln 10 mg/5ml methadone hcl tab 5 mg methadone hcl tab 10 mg MORPHINE SUL INJ 2MG/ML $0 $0 $0 $0 $0 $0 (1) (1) (1) (1) (1) (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (120 lozenges / 30 days), PA QL (120 lozenges / 30 days), PA QL (120 lozenges / 30 days), PA QL (120 lozenges / 30 days), PA QL (10 patches / 30 days) QL (10 patches / 30 days) QL (10 patches / 30 days), PA QL (10 patches / 30 days), PA QL (10 patches / 30 days), PA QL (120 tabs / 30 days), PA QL (120 tabs / 30 days), PA QL (120 tabs / 30 days), PA QL (120 tabs / 30 days), PA QL (120 tabs / 30 days), PA B/D QL (270 tabs / 30 days) QL (270 tabs / 30 days) QL (270 tabs / 30 days) QL (30 bottles / 30 days), PA QL (30 bottles / 30 days), PA QL (120 mL / 30 days) QL (600 mL / 30 days) QL (600 mL / 30 days) QL (240 tabs / 30 days) QL (240 tabs / 30 days) B/D PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 3 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) MORPHINE SUL INJ 4MG/ML $0 (1) MORPHINE SUL INJ 8MG/ML $0 (1) morphine sulfate beads cap sr 24hr 30 mg $0 (1) morphine sulfate beads cap sr 24hr 45 mg $0 (1) morphine sulfate beads cap sr 24hr 60 mg $0 (1) morphine sulfate beads cap sr 24hr 75 mg $0 (1) morphine sulfate beads cap sr 24hr 90 mg $0 (1) morphine sulfate beads cap sr 24hr 120 mg$0 (1) morphine sulfate cap sr 24hr 10 mg $0 (1) morphine sulfate cap sr 24hr 20 mg $0 (1) morphine sulfate cap sr 24hr 30 mg $0 (1) morphine sulfate cap sr 24hr 50 mg $0 (1) morphine sulfate cap sr 24hr 60 mg $0 (1) morphine sulfate cap sr 24hr 80 mg $0-$6.60 (2) morphine sulfate cap sr 24hr 100 mg $0-$6.60 (2) morphine sulfate inj pf 0.5 mg/ml $0 (1) morphine sulfate inj pf 1 mg/ml $0 (1) MORPHINE SULFATE IV SOLN 1 MG/ML $0 (1) MORPHINE SULFATE IV SOLN PF 10 MG/ML$0 (1) MORPHINE SULFATE IV SOLN PF 15 MG/ML$0 (1) MORPHINE SULFATE ORAL SOLN 10 $0 (1) MG/5ML MORPHINE SULFATE ORAL SOLN 20 $0 (1) MG/5ML MORPHINE SULFATE ORAL SOLN 100 $0 (1) MG/5ML (20 MG/ML) MORPHINE SULFATE TAB 15 MG $0 (1) MORPHINE SULFATE TAB 30 MG $0 (1) morphine sulfate tab cr 15 mg $0 (1) morphine sulfate tab cr 30 mg $0 (1) morphine sulfate tab cr 60 mg $0 (1) morphine sulfate tab cr 100 mg $0 (1) morphine sulfate tab cr 200 mg $0 (1) oxycodone hcl cap 5 mg $0 (1) OXYCODONE HCL CONC 100 MG/5ML (20 $0 (1) MG/ML) oxycodone hcl soln 5 mg/5ml $0 (1) oxycodone hcl tab 5 mg $0 (1) oxycodone hcl tab 10 mg $0 (1) oxycodone hcl tab 15 mg $0 (1) oxycodone hcl tab 20 mg $0 (1) oxycodone hcl tab 30 mg $0 (1) oxycodone w/ acetaminophen tab 2.5-325 $0 (1) mg NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE B/D B/D QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 QL (60 B/D B/D B/D B/D B/D caps caps caps caps caps caps caps caps caps caps caps caps caps / / / / / / / / / / / / / 30 30 30 30 30 30 30 30 30 30 30 30 30 days) days) days) days) days) days) days) days) days) days) days) days) days) QL QL QL QL QL QL QL QL (180 tabs / 30 days) (180 tabs / 30 days) (90 tabs / 30 days) (90 tabs / 30 days) (90 tabs / 30 days) (90 tabs / 30 days) (60 tabs / 30 days) (180 caps / 30 days) QL QL QL QL QL QL (180 (180 (180 (180 (180 (360 tabs tabs tabs tabs tabs tabs / / / / / / 30 30 30 30 30 30 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid days) days) days) days) days) days) 4 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) oxycodone w/ acetaminophen tab 5-325 mg oxycodone w/ acetaminophen tab 7.5-325 $0 (1) mg oxycodone w/ acetaminophen tab 10-325 $0 (1) mg roxicet sol 5-325/5 $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (1800 mL / 30 days) ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS lidocaine lidocaine lidocaine lidocaine lidocaine 0.5% lidocaine 1% hcl hcl hcl hcl hcl local local local local local inj 0.5% $0 inj 1% $0 inj 1.5% $0 inj 2% $0 preservative free (pf) inj $0 (1) (1) (1) (1) (1) B/D B/D B/D B/D B/D hcl local preservative free (pf) inj $0 (1) B/D ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate inj 1 gm/4ml (250 mg/ml)$0 (1) amikacin sulfate inj 500 mg/2ml (250 $0 (1) mg/ml) gentam/nacl inj 0.9mg/ml $0 (1) gentam/nacl inj 1.4mg/ml $0 (1) gentamicin in saline inj 0.8 mg/ml $0 (1) gentamicin in saline inj 1 mg/ml $0 (1) gentamicin in saline inj 1.2 mg/ml $0 (1) gentamicin in saline inj 1.6 mg/ml $0 (1) gentamicin in saline inj 2 mg/ml $0 (1) gentamicin sulfate inj 10 mg/ml $0 (1) gentamicin sulfate inj 40 mg/ml $0 (1) gentamicin sulfate iv soln 10 mg/ml $0 (1) neomycin sulfate tab 500 mg $0 (1) paromomycin sulfate cap 250 mg $0 (1) streptomycin sulfate for inj 1 gm $0 (1) sulfadiazine tab 500mg $0-$6.60 (2) tobra/nacl inj 80/0.9 $0-$6.60 (2) tobramycin nebu soln 300 mg/5ml $0-$6.60 (2) tobramycin sulfate for inj 1.2 gm $0 (1) tobramycin sulfate inj 1.2 gm/30ml (40 $0 (1) mg/ml) tobramycin sulfate inj 2 gm/50ml (40 $0 (1) mg/ml) B/D, NM PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 5 Drug Name (By Medical Condition) tobramycin sulfate inj 10 mg/ml tobramycin sulfate inj 80 mg/2ml (40 mg/ml) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0 (1) ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 200MG $0-$6.60 (2) ALINIA SUS 100/5ML $0-$6.60 (2) ALINIA TAB 500MG $0-$6.60 (2) atovaquone susp 750 mg/5ml $0-$6.60 (2) AZACTAM INJ 1GM $0-$6.60 (2) AZACTAM INJ 2GM $0-$6.60 (2) AZACTAM/DEX INJ 1GM $0-$6.60 (2) AZACTAM/DEX INJ 2GM $0-$6.60 (2) aztreonam for inj 1 gm $0 (1) aztreonam for inj 2 gm $0 (1) BILTRICIDE TAB 600MG $0-$6.60 (2) CAYSTON INH 75MG $0-$6.60 (2) NM, LA, PA clindamycin hcl cap 75 mg $0 (1) clindamycin hcl cap 150 mg $0 (1) clindamycin hcl cap 300 mg $0 (1) clindamycin palmitate hcl for soln 75 $0 (1) mg/5ml (base equiv) clindamycin phosphate inj 9 gm/60ml $0 (1) clindamycin phosphate inj 300 mg/2ml $0 (1) clindamycin phosphate inj 600 mg/4ml $0 (1) clindamycin phosphate inj 900 mg/6ml $0 (1) clindamycin phosphate iv soln 300 mg/2ml $0 (1) clindamycin phosphate iv soln 600 mg/4ml $0 (1) clindamycin phosphate iv soln 900 mg/6ml $0 (1) colistimethate sodium for inj 150 mg $0 (1) CUBICIN SOL 500MG $0-$6.60 (2) dapsone tab 25 mg $0 (1) dapsone tab 100 mg $0 (1) DARAPRIM TAB 25MG $0-$6.60 (2) imipenem-cilastatin intravenous for soln $0 (1) 250 mg imipenem-cilastatin intravenous for soln $0 (1) 500 mg INVANZ INJ 1GM $0-$6.60 (2) ivermectin tab 3 mg $0 (1) linezolid iv soln 2 mg/ml $0-$6.60 (2) LINEZOLID TAB 600 MG $0-$6.60 (2) meropenem iv for soln 1 gm $0 (1) meropenem iv for soln 500 mg $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 6 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0 (1) methenamine hippurate tab 1 gm metronidazole in nacl 0.79% iv soln 500 mg/100ml metronidazole tab 250 mg $0 (1) metronidazole tab 500 mg $0 (1) NEBUPENT INH 300MG $0-$6.60 nitrofurantoin macrocrystalline cap 50 mg $0-$6.60 nitrofurantoin macrocrystalline cap 100 mg$0-$6.60 nitrofurantoin monohydrate $0-$6.60 macrocrystalline cap 100 mg PENTAM 300 INJ 300MG $0-$6.60 SIVEXTRO INJ 200MG $0-$6.60 SIVEXTRO TAB 200MG $0-$6.60 sulfamethoxazole-trimethoprim iv soln $0 (1) 400-80 mg/5ml sulfamethoxazole-trimethoprim susp $0 (1) 200-40 mg/5ml sulfamethoxazole-trimethoprim tab 400-80$0 (1) mg sulfamethoxazole-trimethoprim tab $0 (1) 800-160 mg SYNERCID INJ 500MG $0-$6.60 trimethoprim tab 100 mg $0 (1) TYGACIL INJ 50MG $0-$6.60 vancomycin hcl cap 125 mg $0-$6.60 vancomycin hcl cap 250 mg $0-$6.60 vancomycin hcl for inj 10 gm $0 (1) vancomycin hcl for inj 500 mg $0 (1) vancomycin hcl for inj 1000 mg $0 (1) vancomycin hcl for inj 5000 mg $0 (1) vancomycin inj 750mg $0 (1) ZYVOX SUS 100MG/5M $0-$6.60 ZYVOX TAB 600MG $0-$6.60 (2) (2) (2) (2) B/D PA; 90 day limit if >64 yr PA; 90 day limit if >64 yr PA; 90 day limit if >64 yr (2) (2) (2) (2) (2) (2) (2) (2) (2) ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ABELCET INJ 5MG/ML AMBISOME INJ 50MG amphotericin b for inj 50 mg CANCIDAS INJ 50MG CANCIDAS INJ 70MG ERAXIS INJ 50MG ERAXIS INJ 100MG fluconazole for susp 10 mg/ml fluconazole for susp 40 mg/ml $0-$6.60 $0-$6.60 $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) (2) (2) B/D B/D B/D (2) (2) (2) (2) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 7 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) fluconazole in dextrose inj 200 mg/100ml $0 (1) fluconazole in dextrose inj 400 mg/200ml $0 (1) fluconazole in nacl 0.9% inj 200 mg/100ml$0 (1) fluconazole in nacl 0.9% inj 400 mg/200ml$0 (1) fluconazole tab 50 mg $0 (1) fluconazole tab 100 mg $0 (1) fluconazole tab 150 mg $0 (1) fluconazole tab 200 mg $0 (1) flucytosine cap 250 mg $0-$6.60 (2) flucytosine cap 500 mg $0-$6.60 (2) griseofulvin microsize susp 125 mg/5ml $0 (1) griseofulvin microsize tab 500 mg $0 (1) griseofulvin ultramicrosize tab 125 mg $0 (1) griseofulvin ultramicrosize tab 250 mg $0 (1) itraconazole cap 100 mg $0 (1) ketoconazole tab 200 mg $0 (1) MYCAMINE INJ 50MG $0-$6.60 (2) MYCAMINE INJ 100MG $0-$6.60 (2) NOXAFIL SUS 40MG/ML $0-$6.60 (2) NOXAFIL TAB 100MG $0-$6.60 (2) nystatin tab 500000 unit $0 (1) terbinafine hcl tab 250 mg $0 (1) voriconazole for inj 200 mg $0 (1) voriconazole for susp 40 mg/ml $0-$6.60 (2) voriconazole tab 50 mg $0-$6.60 (2) voriconazole tab 200 mg $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE PA PA QL (90 tabs / 365 days) ANTIMALARIALS - DRUGS TO TREAT MALARIA atovaquone-proguanil hcl tab 62.5-25 mg atovaquone-proguanil hcl tab 250-100 mg chloroquine phosphate tab 250 mg chloroquine phosphate tab 500 mg COARTEM TAB 20-120MG mefloquine hcl tab 250 mg PRIMAQUINE TAB 26.3MG quinine sulfate cap 324 mg $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0 (1) $0-$6.60 (2) $0 (1) PA ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate tab 300 mg (base equiv) $0 (1) APTIVUS CAP 250MG $0-$6.60 (2) APTIVUS SOL $0-$6.60 (2) CRIXIVAN CAP 200MG $0-$6.60 (2) CRIXIVAN CAP 400MG $0-$6.60 (2) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 8 Drug Name (By Medical Condition) didanosine delayed release capsule didanosine delayed release capsule didanosine delayed release capsule didanosine delayed release capsule EDURANT TAB 25MG EMTRIVA CAP 200MG EMTRIVA SOL 10MG/ML EPIVIR SOL 10MG/ML FUZEON INJ 90MG INTELENCE TAB 25MG INTELENCE TAB 100MG INTELENCE TAB 200MG INVIRASE CAP 200MG INVIRASE TAB 500MG ISENTRESS CHW 25MG ISENTRESS CHW 100MG ISENTRESS POW 100MG ISENTRESS TAB 400MG lamivudine oral soln 10 mg/ml lamivudine tab 150 mg lamivudine tab 300 mg LEXIVA SUS 50MG/ML LEXIVA TAB 700MG NEVIRAPINE SUSP 50 MG/5ML nevirapine tab 200 mg nevirapine tab sr 24hr 400 mg NORVIR CAP 100MG NORVIR SOL 80MG/ML NORVIR TAB 100MG PREZISTA SUS 100MG/ML PREZISTA TAB 75MG PREZISTA TAB 150MG PREZISTA TAB 600MG PREZISTA TAB 800MG RESCRIPTOR TAB 100 MG RESCRIPTOR TAB 200MG RETROVIR INJ 10MG/ML REYATAZ CAP 150MG REYATAZ CAP 200MG REYATAZ CAP 300MG REYATAZ POW 50MG SELZENTRY TAB 150MG WHAT THE DRUG WILL COST YOU (TIER LEVEL) 125 mg$0 (1) 200 mg$0 (1) 250 mg$0 (1) 400 mg$0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE NM PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 9 Drug Name (By Medical Condition) SELZENTRY TAB 300MG stavudine cap 15 mg stavudine cap 20 mg stavudine cap 30 mg stavudine cap 40 mg stavudine for oral soln 1 mg/ml SUSTIVA CAP 50MG SUSTIVA CAP 200MG SUSTIVA TAB 600MG TIVICAY TAB 50MG TYBOST TAB 150MG VIDEX SOL 2GM VIDEX SOL 4GM VIRACEPT TAB 250MG VIRACEPT TAB 625MG VIRAMUNE XR TAB 100MG VIREAD POW 40MG/GM VIREAD TAB 150MG VIREAD TAB 200MG VIREAD TAB 250MG VIREAD TAB 300MG VITEKTA TAB 85MG VITEKTA TAB 150MG ZIAGEN SOL 20MG/ML zidovudine cap 100 mg zidovudine syrup 10 mg/ml zidovudine tab 300 mg WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine-zidovudine tab $0-$6.60 300-150-300 mg ATRIPLA TAB $0-$6.60 COMPLERA TAB $0-$6.60 EPZICOM TAB 600-300 $0-$6.60 EVOTAZ TAB 300-150 $0-$6.60 KALETRA SOL $0-$6.60 KALETRA TAB 100-25MG $0-$6.60 KALETRA TAB 200-50MG $0-$6.60 lamivudine-zidovudine tab 150-300 mg $0-$6.60 PREZCOBIX TAB 800-150 $0-$6.60 STRIBILD TAB $0-$6.60 TRIUMEQ TAB $0-$6.60 (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 10 Drug Name (By Medical Condition) TRUVADA TAB 200-300 WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (30 tabs / 30 days) ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS CAPASTAT SUL INJ 1GM cycloserine cap 250 mg ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg isoniazid inj 100 mg/ml isoniazid syrup 50 mg/5ml isoniazid tab 100 mg isoniazid tab 300 mg paser gra 4gm PRIFTIN TAB 150MG pyrazinamide tab 500 mg rifabutin cap 150 mg rifampin cap 150 mg rifampin cap 300 mg rifampin for inj 600 mg RIFATER TAB SIRTURO TAB 100MG TRECATOR TAB 250MG $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) (2) (2) LA, PA ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir cap 200 mg acyclovir sodium for inj 500 mg acyclovir sodium for inj 1000 mg acyclovir sodium iv soln 50 mg/ml acyclovir susp 200 mg/5ml acyclovir tab 400 mg acyclovir tab 800 mg adefovir dipivoxil tab 10 mg BARACLUDE SOL .05MG/ML entecavir tab 0.5 mg entecavir tab 1 mg EPIVIR HBV SOL 5MG/ML famciclovir tab 125 mg famciclovir tab 250 mg famciclovir tab 500 mg ganciclovir sodium for inj 500 mg HARVONI TAB 90-400MG lamivudine tab 100 mg (hbv) moderiba pak 600/day moderiba pak 800/day moderiba pak 1000/day $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 B/D B/D B/D (2) (2) (2) (2) (2) (2) B/D NM, PA (2) (2) (2) NM, PA NM, PA NM, PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 11 Drug Name (By Medical Condition) moderiba pak 1200/day OLYSIO CAP 150MG REBETOL SOL 40MG/ML RELENZA MIS DISKHALE ribapak pak 600/day ribapak pak 800/day ribapak pak 1000/day ribapak pak 1200/day ribasphere cap 200mg ribasphere tab 200mg ribasphere tab 400mg ribasphere tab 600mg ribavirin cap 200 mg ribavirin tab 200 mg rimantadine hydrochloride tab 100 mg SOVALDI TAB 400MG TAMIFLU CAP 30MG TAMIFLU CAP 45MG TAMIFLU CAP 75MG TAMIFLU SUS 6MG/ML TYZEKA TAB 600MG valacyclovir hcl tab 1 gm valacyclovir hcl tab 500 mg VALCYTE SOL 50MG/ML valganciclovir hcl tab 450 mg (base equivalent) VICTRELIS CAP 200MG WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE $0-$6.60 (2) NM, PA NM, PA NM, PA NM, PA NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, PA PA PA PA PA PA PA PA PA PA NM, PA CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor cap 250 mg cefaclor cap 500 mg cefaclor er tab 500mg cefaclor for susp 125 mg/5ml cefaclor for susp 250 mg/5ml cefaclor for susp 375 mg/5ml cefadroxil cap 500 mg cefadroxil for susp 250 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm cefazolin inj 1gm/50ml cefazolin sodium for inj 1 gm cefazolin sodium for inj 10 gm cefazolin sodium for inj 20 gm cefazolin sodium for inj 500 mg $0 (1) $0 (1) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 12 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) cefazolin sodium for iv soln 1 gm $0 (1) cefdinir cap 300 mg $0 (1) cefdinir for susp 125 mg/5ml $0 (1) cefdinir for susp 250 mg/5ml $0 (1) cefepime hcl for inj 1 gm $0 (1) cefepime hcl for inj 2 gm $0 (1) cefixime for susp 100 mg/5ml $0 (1) cefixime for susp 200 mg/5ml $0 (1) cefotaxime sodium for inj 1 gm $0 (1) cefotaxime sodium for inj 2 gm $0 (1) cefotaxime sodium for inj 500 mg $0 (1) cefoxitin sodium for inj 10 gm $0 (1) cefoxitin sodium for iv soln 1 gm $0 (1) cefoxitin sodium for iv soln 2 gm $0 (1) cefpodoxime proxetil for susp 50 mg/5ml $0 (1) cefpodoxime proxetil for susp 100 mg/5ml $0 (1) cefpodoxime proxetil tab 100 mg $0 (1) cefpodoxime proxetil tab 200 mg $0 (1) cefprozil for susp 125 mg/5ml $0 (1) cefprozil for susp 250 mg/5ml $0 (1) cefprozil tab 250 mg $0 (1) cefprozil tab 500 mg $0 (1) ceftazidime for inj 1 gm $0 (1) ceftazidime for inj 2 gm $0 (1) ceftazidime for inj 6 gm $0 (1) CEFTAZIDIME/ SOL D5W 1GM $0-$6.60 (2) CEFTAZIDIME/ SOL D5W 2GM $0-$6.60 (2) ceftriaxone sodium for inj 1 gm $0 (1) ceftriaxone sodium for inj 2 gm $0 (1) ceftriaxone sodium for inj 10 gm $0 (1) ceftriaxone sodium for inj 250 mg $0 (1) ceftriaxone sodium for inj 500 mg $0 (1) ceftriaxone sodium for iv soln 1 gm $0 (1) ceftriaxone sodium for iv soln 2 gm $0 (1) cefuroxime axetil tab 250 mg $0 (1) cefuroxime axetil tab 500 mg $0 (1) cefuroxime inj 7.5gm $0 (1) cefuroxime sodium for inj 1.5 gm $0 (1) cefuroxime sodium for inj 7.5 gm $0 (1) cefuroxime sodium for inj 750 mg $0 (1) cefuroxime sodium for iv soln 1.5 gm $0 (1) cephalexin cap 250 mg $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 13 Drug Name (By Medical Condition) cephalexin cap 500 mg cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml SUPRAX CAP 400MG suprax chw 100mg suprax chw 200mg suprax sus 100/5ml suprax sus 200/5ml SUPRAX SUS 500/5ML tazicef inj 1gm tazicef inj 2gm tazicef inj 6gm TEFLARO INJ 400MG TEFLARO INJ 600MG WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS azithromycin for susp 100 mg/5ml azithromycin for susp 200 mg/5ml azithromycin iv for soln 500 mg AZITHROMYCIN POWD PACK FOR SUSP 1 GM azithromycin tab 250 mg azithromycin tab 500 mg azithromycin tab 600 mg clarithromycin for susp 125 mg/5ml clarithromycin for susp 250 mg/5ml clarithromycin tab 250 mg clarithromycin tab 500 mg clarithromycin tab sr 24hr 500 mg DIFICID TAB 200MG e.e.s. 400 tab 400mg E.E.S. GRAN SUS 200/5ML ery-tab tab 250mg ec ery-tab tab 333mg ec ery-tab tab 500mg ec ERYPED SUS 200/5ML ERYPED SUS 400/5ML erythrocin inj 500mg erythrocin tab 250mg erythromycin ethylsuccinate tab 400 mg erythromycin tab 250 mg erythromycin tab 500 mg $0 $0 $0 $0 (1) (1) (1) (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) (2) (2) (2) (2) (2) (2) (2) (2) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 14 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) erythromycin w/ delayed release particles $0 (1) cap 250 mg ZMAX SUS 2GM $0-$6.60 (2) FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ciprofloxacin 200 mg/100ml in d5w ciprofloxacin 400 mg/200ml in d5w ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 mg (base equiv) ciprofloxacin hcl tab 250 mg (base equiv) ciprofloxacin hcl tab 500 mg (base equiv) ciprofloxacin hcl tab 750 mg (base equiv) ciprofloxacin iv soln 200 mg/20ml (1%) ciprofloxacin iv soln 400 mg/40ml (1%) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) levofloxacin in d5w iv soln 250 mg/50ml levofloxacin in d5w iv soln 500 mg/100ml levofloxacin in d5w iv soln 750 mg/150ml levofloxacin iv soln 25 mg/ml levofloxacin oral soln 25 mg/ml levofloxacin tab 250 mg levofloxacin tab 500 mg levofloxacin tab 750 mg $0 (1) $0 (1) $0 (1) $0 (1) $0 $0 $0 $0 $0 $0 $0 (1) (1) (1) (1) (1) (1) (1) $0 (1) $0 $0 $0 $0 $0 $0 $0 $0 (1) (1) (1) (1) (1) (1) (1) (1) PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin & k clavulanate chew tab $0 200-28.5 mg amoxicillin & k clavulanate chew tab 400-57$0 mg amoxicillin & k clavulanate for susp $0 200-28.5 mg/5ml amoxicillin & k clavulanate for susp $0 250-62.5 mg/5ml amoxicillin & k clavulanate for susp 400-57$0 mg/5ml amoxicillin & k clavulanate for susp $0 600-42.9 mg/5ml amoxicillin & k clavulanate tab 250-125 mg$0 amoxicillin & k clavulanate tab 500-125 mg$0 (1) (1) (1) (1) (1) (1) (1) (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 15 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) amoxicillin & k clavulanate tab 875-125 mg$0 (1) amoxicillin & k clavulanate tab sr 12hr $0 (1) 1000-62.5 mg amoxicillin (trihydrate) cap 250 mg $0 (1) amoxicillin (trihydrate) cap 500 mg $0 (1) amoxicillin (trihydrate) chew tab 125 mg $0 (1) amoxicillin (trihydrate) chew tab 250 mg $0 (1) amoxicillin (trihydrate) for susp 125 $0 (1) mg/5ml amoxicillin (trihydrate) for susp 200 $0 (1) mg/5ml amoxicillin (trihydrate) for susp 250 $0 (1) mg/5ml amoxicillin (trihydrate) for susp 400 $0 (1) mg/5ml amoxicillin (trihydrate) tab 500 mg $0 (1) amoxicillin (trihydrate) tab 875 mg $0 (1) ampicillin & sulbactam sodium for inj 1-0.5 $0 (1) gm ampicillin & sulbactam sodium for inj 2-1 $0 (1) gm ampicillin & sulbactam sodium for inj 10-5 $0 (1) gm ampicillin & sulbactam sodium for iv soln $0 (1) 1-0.5 gm ampicillin & sulbactam sodium for iv soln $0 (1) 2-1 gm ampicillin & sulbactam sodium for iv soln $0 (1) 10-5 gm ampicillin cap 250 mg $0 (1) ampicillin cap 500 mg $0 (1) ampicillin for susp 125 mg/5ml $0 (1) ampicillin for susp 250 mg/5ml $0 (1) ampicillin sodium for inj 1 gm $0 (1) ampicillin sodium for inj 2 gm $0 (1) ampicillin sodium for inj 125 mg $0 (1) ampicillin sodium for inj 250 mg $0 (1) ampicillin sodium for inj 500 mg $0 (1) ampicillin sodium for iv soln 1 gm $0 (1) ampicillin sodium for iv soln 2 gm $0 (1) ampicillin sodium for iv soln 10 gm $0 (1) BICILLIN L-A INJ 600000 $0-$6.60 (2) BICILLIN L-A INJ 1200000 $0-$6.60 (2) BICILLIN L-A INJ 2400000 $0-$6.60 (2) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not 16 available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) dicloxacillin sodium cap 250 mg $0 (1) dicloxacillin sodium cap 500 mg $0 (1) nafcillin sodium for inj 1 gm $0 (1) nafcillin sodium for inj 2 gm $0-$6.60 (2) nafcillin sodium for inj 10 gm $0-$6.60 (2) nafcillin sodium for iv soln 1 gm $0 (1) nafcillin sodium for iv soln 2 gm $0-$6.60 (2) oxacillin sodium for inj 1 gm $0 (1) oxacillin sodium for inj 2 gm $0 (1) oxacillin sodium for inj 10 gm $0-$6.60 (2) pen g proc inj 600000 $0-$6.60 (2) PENICILL GK/ INJ DEX 2MU $0-$6.60 (2) PENICILL GK/ INJ DEX 3MU $0-$6.60 (2) penicillin g potassium for inj 5000000 unit $0 (1) penicillin g potassium for inj 20000000 unit$0 (1) penicillin g sodium for inj 5000000 unit $0 (1) penicillin v potassium for soln 125 mg/5ml $0 (1) penicillin v potassium for soln 250 mg/5ml $0 (1) penicillin v potassium tab 250 mg $0 (1) penicillin v potassium tab 500 mg $0 (1) piperacillin sodium-tazobactam sodium for $0 (1) inj 2-0.25 gm piperacillin sodium-tazobactam sodium for $0 (1) inj 3-0.375 gm piperacillin sodium-tazobactam sodium for $0 (1) inj 4-0.5 gm piperacillin sodium-tazobactam sodium for $0 (1) inj 36-4.5 gm TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxycycline hyclate cap 50 mg $0 (1) doxycycline hyclate cap 100 mg $0 (1) doxycycline hyclate for inj 100 mg $0 (1) doxycycline hyclate tab 20 mg $0 (1) doxycycline hyclate tab 100 mg $0 (1) doxycycline monohydrate cap 50 mg $0 (1) doxycycline monohydrate cap 100 mg $0 (1) doxycycline monohydrate tab 50 mg $0 (1) doxycycline monohydrate tab 75 mg $0 (1) doxycycline monohydrate tab 100 mg $0 (1) doxycycline monohydrate tab 150 mg $0 (1) minocycline hcl cap 50 mg $0 (1) minocycline hcl cap 75 mg $0 (1) minocycline hcl cap 100 mg $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 17 Drug Name (By Medical Condition) VIBRAMYCIN SYP 50MG/5ML WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0-$6.60 (2) ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS BICNU INJ 100MG BUSULFEX INJ 6MG/ML CYCLOPHOSPH CAP 25MG CYCLOPHOSPH CAP 50MG cyclophosphamide for inj 1 gm cyclophosphamide for inj 2 gm cyclophosphamide for inj 500 mg dacarbazine for inj 100 mg dacarbazine for inj 200 mg EMCYT CAP 140MG GLEOSTINE CAP 10MG GLEOSTINE CAP 40MG GLEOSTINE CAP 100MG HEXALEN CAP 50MG IFEX INJ 3GM ifosfamide for inj 1 gm IFOSFAMIDE INJ 3GM ifosfamide iv inj 1 gm/20ml (50 mg/ml) ifosfamide iv inj 3 gm/60ml (50 mg/ml) LEUKERAN TAB 2MG LOMUSTINE CAP 10 MG LOMUSTINE CAP 40 MG LOMUSTINE CAP 100 MG melphalan hcl for inj 50 mg (base equiv) MUSTARGEN INJ 10MG TREANDA INJ 25MG TREANDA INJ 45/0.5ML TREANDA INJ 100MG TREANDA INJ 180/2ML $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0-$6.60 $0 (1) $0 (1) $0-$6.60 $0 (1) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D (2) (2) (2) (2) (2) (2) (2) B/D B/D B/D, B/D, B/D, B/D, NM NM NM NM ANTHRACYCLINES adriamyc inj 50mg $0 (1) daunorubicin hcl inj 5 mg/ml (base equiv) $0 (1) doxorubicin hcl for inj 50 mg $0 (1) doxorubicin hcl inj 2 mg/ml $0 (1) doxorubicin hcl liposomal inj (for iv $0-$6.60 (2) infusion) 2 mg/ml epirubicin hcl iv soln 50 mg/25ml (2 mg/ml)$0 (1) epirubicin hcl iv soln 200 mg/100ml (2 $0 (1) mg/ml) idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) $0-$6.60 (2) B/D B/D B/D B/D B/D B/D B/D B/D PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 18 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) $0-$6.60 (2) idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE B/D B/D ANTIBIOTICS bleomycin sulfate for bleomycin sulfate for mitomycin for iv soln mitomycin for iv soln mitomycin for iv soln inj 15 unit inj 30 unit 5 mg 20 mg 40 mg $0 $0 $0 $0 $0 (1) (1) (1) (1) (1) B/D B/D B/D B/D B/D ANTIMETABOLITES adrucil inj 500/10ml ALIMTA INJ 100MG ALIMTA INJ 500MG azacitidine for inj 100 mg cladribine inj 1 mg/ml cytarabine inj 20 mg/ml fludarabine phosphate for inj 50 mg fludarabine phosphate inj 25 mg/ml fluorouracil inj 1 gm/20ml (50 mg/ml) fluorouracil inj 2.5 gm/50ml (50 mg/ml) fluorouracil inj 5 gm/100ml (50 mg/ml) fluorouracil inj 500 mg/10ml (50 mg/ml) gemcitabine hcl for inj 1 gm gemcitabine hcl for inj 2 gm gemcitabine hcl for inj 200 mg GEMCITABINE INJ 1GM GEMCITABINE INJ 2GM GEMCITABINE INJ 200MG mercaptopurine tab 50 mg methotrexate sodium for inj 1 gm methotrexate sodium inj 25 mg/ml methotrexate sodium inj pf 25 mg/ml NIPENT INJ 10MG PURIXAN SUS 20MG/ML TABLOID TAB 40MG $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) B/D B/D B/D B/D, NM B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D ANTIMITOTIC, TAXOIDS DOCETAXEL FOR INJ CONC 20 MG/ML $0-$6.60 DOCETAXEL FOR INJ CONC 80 MG/4ML (20$0-$6.60 MG/ML) DOCETAXEL INJ 20MG/2ML $0 (1) DOCETAXEL INJ 80MG/8ML $0-$6.60 docetaxel inj 140/7ml $0-$6.60 DOCETAXEL INJ 160/16ML $0-$6.60 DOCETAXEL INJ 200MG/20 $0-$6.60 (2) (2) B/D B/D (2) (2) (2) (2) B/D B/D B/D B/D B/D PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 19 Drug Name (By Medical Condition) paclitaxel paclitaxel mg/ml) paclitaxel paclitaxel iv conc 30 mg/5ml (6 mg/ml) iv conc 100 mg/16.7ml (6 WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0 (1) iv conc 150 mg/25ml (6 mg/ml) $0 (1) iv conc 300 mg/50ml (6 mg/ml) $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE B/D B/D B/D B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine inj 1mg/ml vincasar pfs inj 1mg/ml vincristine sulfate iv soln 1 mg/ml vinorelbine tartrate inj 10 mg/ml (base equiv) vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) B/D B/D B/D B/D $0 (1) B/D BIOLOGIC RESPONSE MODIFIERS AVASTIN INJ AVASTIN INJ 400/16ML ERIVEDGE CAP 150MG FARYDAK CAP 10MG FARYDAK CAP 15MG FARYDAK CAP 20MG HERCEPTIN INJ 440MG IBRANCE CAP 75MG IBRANCE CAP 100MG IBRANCE CAP 125MG ISTODAX INJ 10MG KADCYLA INJ 100MG KADCYLA INJ 160MG LYNPARZA CAP 50MG PROLEUKIN INJ 22MU RITUXAN INJ 500MG VELCADE INJ 3.5MG ZOLINZA CAP 100MG $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) B/D, NM B/D, NM NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA B/D, NM NM, LA, PA NM, LA, PA NM, LA, PA B/D, NM B/D, NM B/D, NM NM, PA B/D, NM NM, PA B/D, NM NM, PA (2) B/D (2) (2) B/D (2) NM, PA NM, PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole tab 1 mg bicalutamide tab 50 mg DEPO-PROVERA INJ 400/ML exemestane tab 25 mg FARESTON TAB 60MG FASLODEX INJ 250MG flutamide cap 125 mg letrozole tab 2.5 mg leuprolide acetate inj kit 5 mg/ml LUPR DEP-PED INJ 7.5MG $0 (1) $0 (1) $0-$6.60 $0 (1) $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0-$6.60 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 20 Drug Name (By Medical Condition) LUPR DEP-PED INJ 11.25MG LUPR DEP-PED INJ 15MG LUPR DEP-PED INJ 30MG LUPRON DEPOT INJ 3.75MG LUPRON DEPOT INJ 11.25MG LYSODREN TAB 500MG MEGACE ES SUS 625/5ML megestrol acetate susp 40 mg/ml WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) MEGESTROL ACETATE SUSP 625 MG/5ML $0-$6.60 (2) megestrol acetate tab 20 mg $0-$6.60 (2) megestrol acetate tab 40 mg $0-$6.60 (2) NILANDRON TAB 150MG SOLTAMOX SOL 10MG/5ML tamoxifen citrate tab 10 mg (base equivalent) tamoxifen citrate tab 20 mg (base equivalent) TRELSTAR MIX INJ 3.75MG TRELSTAR MIX INJ 11.25MG XTANDI CAP 40MG ZYTIGA TAB 250MG $0-$6.60 (2) $0-$6.60 (2) $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE NM, NM, NM, NM, NM, PA PA PA PA PA PA PA; PA for age 65 or older PA PA; PA for age 65 or older PA; PA for age 65 or older $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) NM, NM, NM, NM, PA PA LA, PA PA KINASE INHIBITORS AFINITOR DIS TAB 2MG $0-$6.60 (2) NM, PA AFINITOR DIS TAB 3MG $0-$6.60 (2) NM, PA AFINITOR DIS TAB 5MG $0-$6.60 (2) NM, PA AFINITOR TAB 2.5MG $0-$6.60 (2) NM, PA AFINITOR TAB 5MG $0-$6.60 (2) NM, PA AFINITOR TAB 7.5MG $0-$6.60 (2) NM, PA AFINITOR TAB 10MG $0-$6.60 (2) NM, PA BOSULIF TAB 100MG $0-$6.60 (2) NM, PA BOSULIF TAB 500MG $0-$6.60 (2) NM, PA CAPRELSA TAB 100MG $0-$6.60 (2) NM, LA, PA CAPRELSA TAB 300MG $0-$6.60 (2) NM, LA, PA COMETRIQ KIT 60MG $0-$6.60 (2) NM, PA COMETRIQ KIT 100MG $0-$6.60 (2) NM, PA COMETRIQ KIT 140MG $0-$6.60 (2) NM, PA GILOTRIF TAB 20MG $0-$6.60 (2) NM, LA, PA GILOTRIF TAB 30MG $0-$6.60 (2) NM, LA, PA GILOTRIF TAB 40MG $0-$6.60 (2) NM, LA, PA GLEEVEC TAB 100MG $0-$6.60 (2) NM, PA GLEEVEC TAB 400MG $0-$6.60 (2) NM, PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 21 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) ICLUSIG TAB 15MG $0-$6.60 (2) NM, LA, PA ICLUSIG TAB 45MG $0-$6.60 (2) NM, LA, PA IMBRUVICA CAP 140MG $0-$6.60 (2) NM, LA, PA INLYTA TAB 1MG $0-$6.60 (2) NM, LA, PA INLYTA TAB 5MG $0-$6.60 (2) NM, LA, PA IRESSA TAB 250MG $0-$6.60 (2) NM, LA, PA JAKAFI TAB 5MG $0-$6.60 (2) NM, LA, PA JAKAFI TAB 10MG $0-$6.60 (2) NM, LA, PA JAKAFI TAB 15MG $0-$6.60 (2) NM, LA, PA JAKAFI TAB 20MG $0-$6.60 (2) NM, LA, PA JAKAFI TAB 25MG $0-$6.60 (2) NM, LA, PA LENVIMA CAP 10MG $0-$6.60 (2) NM, LA, PA LENVIMA CAP 14MG $0-$6.60 (2) NM, LA, PA LENVIMA CAP 20MG $0-$6.60 (2) NM, LA, PA LENVIMA CAP 24MG $0-$6.60 (2) NM, LA, PA MEKINIST TAB 0.5MG $0-$6.60 (2) NM, PA MEKINIST TAB 2MG $0-$6.60 (2) NM, PA NEXAVAR TAB 200MG $0-$6.60 (2) NM, LA, PA SPRYCEL TAB 20MG $0-$6.60 (2) NM, PA SPRYCEL TAB 50MG $0-$6.60 (2) NM, PA SPRYCEL TAB 70MG $0-$6.60 (2) NM, PA SPRYCEL TAB 80MG $0-$6.60 (2) NM, PA SPRYCEL TAB 100MG $0-$6.60 (2) NM, PA SPRYCEL TAB 140MG $0-$6.60 (2) NM, PA STIVARGA TAB 40MG $0-$6.60 (2) NM, LA, PA SUTENT CAP 12.5MG $0-$6.60 (2) NM, PA SUTENT CAP 25MG $0-$6.60 (2) NM, PA SUTENT CAP 37.5MG $0-$6.60 (2) NM, PA SUTENT CAP 50MG $0-$6.60 (2) NM, PA TAFINLAR CAP 50MG $0-$6.60 (2) NM, PA TAFINLAR CAP 75MG $0-$6.60 (2) NM, PA TARCEVA TAB 25MG $0-$6.60 (2) NM, PA TARCEVA TAB 100MG $0-$6.60 (2) NM, PA TARCEVA TAB 150MG $0-$6.60 (2) NM, PA TASIGNA CAP 150MG $0-$6.60 (2) NM, PA TASIGNA CAP 200MG $0-$6.60 (2) NM, PA TYKERB TAB 250MG $0-$6.60 (2) NM, LA, PA VOTRIENT TAB 200MG $0-$6.60 (2) NM, PA XALKORI CAP 200MG $0-$6.60 (2) NM, LA, PA XALKORI CAP 250MG $0-$6.60 (2) NM, LA, PA ZELBORAF TAB 240MG $0-$6.60 (2) NM, LA, PA ZYDELIG TAB 100MG $0-$6.60 (2) NM, LA, PA ZYDELIG TAB 150MG $0-$6.60 (2) NM, LA, PA ZYKADIA CAP 150MG $0 (1) NM, LA, PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not 22 available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) MISCELLANEOUS bexarotene cap 75 mg $0-$6.60 (2) DROXIA CAP 200MG $0-$6.60 (2) DROXIA CAP 300MG $0-$6.60 (2) DROXIA CAP 400MG $0-$6.60 (2) hydroxyurea cap 500 mg $0 (1) MATULANE CAP 50MG $0-$6.60 (2) mitoxantrone hcl inj conc 20 mg/10ml (2 $0 (1) mg/ml) mitoxantrone hcl inj conc 25 mg/12.5ml (2$0 (1) mg/ml) mitoxantrone hcl inj conc 30 mg/15ml (2 $0 (1) mg/ml) POMALYST CAP 1MG $0-$6.60 (2) POMALYST CAP 2MG $0-$6.60 (2) POMALYST CAP 3MG $0-$6.60 (2) POMALYST CAP 4MG $0-$6.60 (2) SYLATRON KIT 200MCG $0-$6.60 (2) SYLATRON KIT 300MCG $0-$6.60 (2) SYLATRON KIT 600MCG $0-$6.60 (2) TARGRETIN CAP 75MG $0-$6.60 (2) tretinoin cap 10 mg $0-$6.60 (2) TRISENOX SOL 10MG/10M $0-$6.60 (2) NM, PA B/D, NM B/D, NM B/D, NM NM, NM, NM, NM, NM, NM, NM, NM, LA, LA, LA, LA, PA PA PA PA PA PA PA PA B/D PLATINUM-BASED AGENTS carboplatin iv soln 50 mg/5ml carboplatin iv soln 150 mg/15ml carboplatin iv soln 450 mg/45ml carboplatin iv soln 600 mg/60ml cisplatin inj 50 mg/50ml (1 mg/ml) cisplatin inj 100 mg/100ml (1 mg/ml) cisplatin inj 200 mg/200ml (1 mg/ml) oxaliplatin for iv inj 50 mg oxaliplatin for iv inj 100 mg oxaliplatin iv soln 50 mg/10ml oxaliplatin iv soln 100 mg/20ml $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D PROTECTIVE AGENTS amifostine crystalline for inj 500 mg dexrazoxane for inj 250 mg ELITEK INJ 1.5MG ELITEK INJ 7.5MG leucovorin calcium for inj 50 mg leucovorin calcium for inj 100 mg leucovorin calcium for inj 200 mg $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) (2) (2) (2) (2) B/D B/D B/D B/D B/D B/D B/D PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 23 Drug Name (By Medical Condition) leucovorin calcium for inj 350 mg leucovorin calcium tab 5 mg leucovorin calcium tab 10 mg leucovorin calcium tab 15 mg leucovorin calcium tab 25 mg leucovorin inj calcium mesna inj 100 mg/ml MESNEX TAB 400MG WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE B/D B/D B/D TOPOISOMERASE INHIBITORS etoposide inj 500mg/25ml (20 mg/ml) $0 (1) irinotecan hcl inj 40 mg/2ml (20 mg/ml) $0-$6.60 irinotecan hcl inj 100 mg/5ml (20 mg/ml) $0-$6.60 irinotecan hcl inj 500 mg/25ml (20 mg/ml) $0-$6.60 toposar inj 1gm/50ml $0 (1) topotecan hcl for inj 4 mg $0-$6.60 (2) (2) (2) (2) B/D B/D B/D B/D B/D B/D CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-benazepril hcl cap $0 2.5-10 mg amlodipine besylate-benazepril hcl cap $0 5-10 mg amlodipine besylate-benazepril hcl cap $0 5-20 mg amlodipine besylate-benazepril hcl cap $0 5-40 mg amlodipine besylate-benazepril hcl cap $0 10-20 mg amlodipine besylate-benazepril hcl cap $0 10-40 mg benazepril & hydrochlorothiazide tab $0 5-6.25 mg benazepril & hydrochlorothiazide tab $0 10-12.5 mg benazepril & hydrochlorothiazide tab $0 20-12.5 mg benazepril & hydrochlorothiazide tab 20-25$0 mg captopril & hydrochlorothiazide tab 25-15 $0 mg captopril & hydrochlorothiazide tab 25-25 $0 mg (1) QL (30 caps / 30 days) (1) QL (30 caps / 30 days) (1) QL (30 caps / 30 days) (1) QL (30 caps / 30 days) (1) QL (30 caps / 30 days) (1) (1) (1) (1) (1) (1) (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 24 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) captopril & hydrochlorothiazide tab 50-15 $0 (1) mg captopril & hydrochlorothiazide tab 50-25 $0 (1) mg enalapril maleate & hydrochlorothiazide tab$0 (1) 5-12.5 mg enalapril maleate & hydrochlorothiazide tab$0 (1) 10-25 mg fosinopril sodium & hydrochlorothiazide tab$0 (1) 10-12.5 mg fosinopril sodium & hydrochlorothiazide tab$0 (1) 20-12.5 mg lisinopril & hydrochlorothiazide tab 10-12.5$0 (1) mg lisinopril & hydrochlorothiazide tab 20-12.5$0 (1) mg lisinopril & hydrochlorothiazide tab 20-25 $0 (1) mg moexipril-hydrochlorothiazide tab 7.5-12.5 $0 (1) mg moexipril-hydrochlorothiazide tab 15-12.5 $0 (1) mg moexipril-hydrochlorothiazide tab 15-25 $0 (1) mg quinapril-hydrochlorothiazide tab 10-12.5 $0 (1) mg quinapril-hydrochlorothiazide tab 20-12.5 $0 (1) mg quinapril-hydrochlorothiazide tab 20-25 mg$0 (1) ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl tab 5 mg benazepril hcl tab 10 mg benazepril hcl tab 20 mg benazepril hcl tab 40 mg captopril tab 12.5 mg captopril tab 25 mg captopril tab 50 mg captopril tab 100 mg enalapril maleate tab 2.5 mg enalapril maleate tab 5 mg enalapril maleate tab 10 mg enalapril maleate tab 20 mg fosinopril sodium tab 10 mg fosinopril sodium tab 20 mg $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 25 Drug Name (By Medical Condition) fosinopril sodium tab 40 mg lisinopril tab 2.5 mg lisinopril tab 5 mg lisinopril tab 10 mg lisinopril tab 20 mg lisinopril tab 30 mg lisinopril tab 40 mg moexipril hcl tab 7.5 mg moexipril hcl tab 15 mg perindopril erbumine tab 2 mg perindopril erbumine tab 4 mg perindopril erbumine tab 8 mg quinapril hcl tab 5 mg quinapril hcl tab 10 mg quinapril hcl tab 20 mg quinapril hcl tab 40 mg ramipril cap 1.25 mg ramipril cap 2.5 mg ramipril cap 5 mg ramipril cap 10 mg trandolapril tab 1 mg trandolapril tab 2 mg trandolapril tab 4 mg WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone tab 25 mg eplerenone tab 50 mg spironolactone tab 25 mg spironolactone tab 50 mg spironolactone tab 100 mg $0 $0 $0 $0 $0 (1) (1) (1) (1) (1) ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate tab 1 doxazosin mesylate tab 2 doxazosin mesylate tab 4 doxazosin mesylate tab 8 prazosin hcl cap 1 mg prazosin hcl cap 2 mg prazosin hcl cap 5 mg terazosin hcl cap 1 mg terazosin hcl cap 2 mg terazosin hcl cap 5 mg terazosin hcl cap 10 mg mg mg mg mg $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 26 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-valsartan tab 5-160 $0 (1) mg amlodipine besylate-valsartan tab 5-320 $0 (1) mg amlodipine besylate-valsartan tab 10-160 $0 (1) mg amlodipine besylate-valsartan tab 10-320 $0 (1) mg amlodipine-valsartan-hydrochlorothiazide $0 (1) tab 5-160-12.5 mg amlodipine-valsartan-hydrochlorothiazide $0 (1) tab 5-160-25 mg amlodipine-valsartan-hydrochlorothiazide $0 (1) tab 10-160-12.5 mg amlodipine-valsartan-hydrochlorothiazide $0 (1) tab 10-160-25 mg amlodipine-valsartan-hydrochlorothiazide $0 (1) tab 10-320-25 mg AZOR TAB 5-20MG $0-$6.60 AZOR TAB 5-40MG $0-$6.60 AZOR TAB 10-20MG $0-$6.60 AZOR TAB 10-40MG $0-$6.60 BENICAR HCT TAB 20-12.5 $0-$6.60 BENICAR HCT TAB 40-12.5 $0-$6.60 BENICAR HCT TAB 40-25MG $0-$6.60 losartan potassium & hydrochlorothiazide $0 (1) tab 50-12.5 mg losartan potassium & hydrochlorothiazide $0 (1) tab 100-12.5 mg losartan potassium & hydrochlorothiazide $0 (1) tab 100-25 mg TRIBENZOR20- TAB 5-12.5MG $0-$6.60 TRIBENZOR40- TAB 5-12.5MG $0-$6.60 TRIBENZOR40- TAB 5-25MG $0-$6.60 TRIBENZOR40- TAB 10-12.5 $0-$6.60 TRIBENZOR40- TAB 10-25MG $0-$6.60 valsartan-hydrochlorothiazide tab 80-12.5 $0 (1) mg valsartan-hydrochlorothiazide tab 160-12.5$0 (1) mg valsartan-hydrochlorothiazide tab 160-25 $0 (1) mg QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) (2) (2) (2) (2) (2) (2) (2) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) (2) (2) (2) (2) (2) QL QL QL QL (30 (30 (30 (30 tabs tabs tabs tabs / / / / 30 30 30 30 days) days) days) days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 27 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) valsartan-hydrochlorothiazide tab 320-12.5$0 (1) mg valsartan-hydrochlorothiazide tab 320-25 $0 (1) mg ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE BENICAR TAB 5MG BENICAR TAB 20MG BENICAR TAB 40MG losartan potassium tab 25 mg losartan potassium tab 50 mg losartan potassium tab 100 mg valsartan tab 40 mg valsartan tab 80 mg valsartan tab 160 mg valsartan tab 320 mg $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl inj 150 mg/3ml (50 mg/ml)$0 (1) amiodarone hcl inj 450 mg/9ml (50 mg/ml)$0 (1) amiodarone hcl inj 900 mg/18ml (50 $0 (1) mg/ml) amiodarone hcl tab 100 mg $0 (1) amiodarone hcl tab 200 mg $0 (1) amiodarone hcl tab 400 mg $0 (1) disopyramide phosphate cap 100 mg $0-$6.60 (2) disopyramide phosphate cap 150 mg $0-$6.60 (2) flecainide acetate tab 50 mg flecainide acetate tab 100 mg flecainide acetate tab 150 mg mexiletine hcl cap 150 mg mexiletine hcl cap 200 mg mexiletine hcl cap 250 mg MULTAQ TAB 400MG NORPACE CAP 100MG CR $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) NORPACE CAP 150MG CR $0-$6.60 (2) pacerone tab 100mg pacerone tab 200mg pacerone tab 400mg propafenone hcl cap sr 12hr 225 mg $0 $0 $0 $0 PA; PA for age 65 or older PA; PA for age 65 or older PA; PA for age 65 or older PA; PA for age 65 or older (1) (1) (1) (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 28 Drug Name (By Medical Condition) propafenone hcl cap sr 12hr 325 mg propafenone hcl cap sr 12hr 425 mg propafenone hcl tab 150 mg propafenone hcl tab 225 mg propafenone hcl tab 300 mg quinidine gluconate tab cr 324 mg quinidine sulfate tab 200 mg quinidine sulfate tab 300 mg sorine tab 80mg sorine tab 120mg sorine tab 160mg sorine tab 240mg sotalol hcl (afib/afl) tab 80 mg sotalol hcl (afib/afl) tab 120 mg sotalol hcl (afib/afl) tab 160 mg sotalol hcl tab 80 mg sotalol hcl tab 120 mg sotalol hcl tab 160 mg sotalol hcl tab 240 mg TIKOSYN CAP 125MCG TIKOSYN CAP 250MCG TIKOSYN CAP 500MCG WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE NM NM NM ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO TREAT HIGH CHOLESTEROL atorvastatin calcium tab 10 mg equivalent) atorvastatin calcium tab 20 mg equivalent) atorvastatin calcium tab 40 mg equivalent) atorvastatin calcium tab 80 mg equivalent) CRESTOR TAB 5MG CRESTOR TAB 10MG CRESTOR TAB 20MG CRESTOR TAB 40MG lovastatin tab 10 mg lovastatin tab 20 mg lovastatin tab 40 mg pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg pravastatin sodium tab 40 mg pravastatin sodium tab 80 mg (base $0 (1) QL (30 tabs / 30 days) (base $0 (1) QL (30 tabs / 30 days) (base $0 (1) QL (30 tabs / 30 days) (base $0 (1) QL (30 tabs / 30 days) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) (2) (2) (2) (2) QL QL QL QL QL QL QL QL QL QL QL (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 29 Drug Name (By Medical Condition) simvastatin simvastatin simvastatin simvastatin simvastatin tab tab tab tab tab 5 mg 10 mg 20 mg 40 mg 80 mg WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL QL QL QL QL (30 (30 (30 (30 (30 tabs tabs tabs tabs tabs / / / / / 30 30 30 30 30 days) days) days) days) days) ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL cholestyramine light powder packets 4 gm $0 (1) cholestyramine powder 4 gm/dose $0 (1) cholestyramine powder packets 4 gm $0 (1) choline fenofibrate cap dr 45 mg (fenofibric$0 (1) acid equiv) choline fenofibrate cap dr 135 mg $0 (1) (fenofibric acid equiv) colestipol hcl granule packets 5 gm $0 (1) colestipol hcl granules 5 gm $0 (1) colestipol hcl tab 1 gm $0 (1) fenofibrate micronized cap 43 mg $0 (1) fenofibrate micronized cap 67 mg $0 (1) fenofibrate micronized cap 130 mg $0 (1) fenofibrate micronized cap 134 mg $0 (1) fenofibrate micronized cap 200 mg $0 (1) fenofibrate tab 48 mg $0 (1) fenofibrate tab 54 mg $0 (1) fenofibrate tab 145 mg $0 (1) fenofibrate tab 160 mg $0 (1) gemfibrozil tab 600 mg $0 (1) niacin tab cr 500 mg (antihyperlipidemic) $0 (1) niacin tab cr 750 mg (antihyperlipidemic) $0 (1) niacin tab cr 1000 mg (antihyperlipidemic) $0 (1) niacor tab 500mg $0 (1) omega-3-acid ethyl esters cap 1 gm $0 (1) prevalite pow 4gm $0 (1) VASCEPA CAP 1GM $0-$6.60 WELCHOL PAK 3.75GM $0-$6.60 WELCHOL TAB 625MG $0-$6.60 ZETIA TAB 10MG $0-$6.60 QL (90 tabs / 30 days) (2) (2) (2) (2) BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone tab 50-25 mg atenolol & chlorthalidone tab 100-25 mg $0 (1) $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 30 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg bisoprolol & hydrochlorothiazide tab 5-6.25$0 mg bisoprolol & hydrochlorothiazide tab $0 10-6.25 mg metoprolol & hydrochlorothiazide tab 50-25$0 mg metoprolol & hydrochlorothiazide tab $0 100-25 mg metoprolol & hydrochlorothiazide tab $0 100-50 mg propranolol & hydrochlorothiazide tab $0 40-25 mg propranolol & hydrochlorothiazide tab $0 80-25 mg (1) (1) (1) (1) (1) (1) (1) BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl cap 200 mg acebutolol hcl cap 400 mg atenolol tab 25 mg atenolol tab 50 mg atenolol tab 100 mg bisoprolol fumarate tab 5 mg bisoprolol fumarate tab 10 mg BYSTOLIC TAB 2.5MG BYSTOLIC TAB 5MG BYSTOLIC TAB 10MG BYSTOLIC TAB 20MG carvedilol tab 3.125 mg carvedilol tab 6.25 mg carvedilol tab 12.5 mg carvedilol tab 25 mg labetalol hcl tab 100 mg labetalol hcl tab 200 mg labetalol hcl tab 300 mg metoprolol succinate tab sr 24hr metoprolol succinate tab sr 24hr metoprolol succinate tab sr 24hr metoprolol succinate tab sr 24hr metoprolol tartrate inj 1 mg/ml metoprolol tartrate tab 25 mg metoprolol tartrate tab 50 mg 25 mg 50 mg 100 mg 200 mg $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) (2) (2) (2) (2) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (45 tabs / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 31 Drug Name (By Medical Condition) metoprolol tartrate tab 100 mg nadolol tab 20 mg nadolol tab 40 mg nadolol tab 80 mg pindolol tab 5 mg pindolol tab 10 mg propranolol hcl cap sr 24hr 60 mg propranolol hcl cap sr 24hr 80 mg propranolol hcl cap sr 24hr 120 mg propranolol hcl cap sr 24hr 160 mg propranolol hcl inj 1 mg/ml propranolol hcl oral soln 20 mg/5ml propranolol hcl oral soln 40 mg/5ml propranolol hcl tab 10 mg propranolol hcl tab 20 mg propranolol hcl tab 40 mg propranolol hcl tab 60 mg propranolol hcl tab 80 mg timolol maleate tab 5 mg timolol maleate tab 10 mg timolol maleate tab 20 mg WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS afeditab tab 30mg cr afeditab tab 60mg cr amlodipine besylate tab 2.5 mg amlodipine besylate tab 5 mg amlodipine besylate tab 10 mg diltiazem hcl cap sr 12hr 60 mg diltiazem hcl cap sr 12hr 90 mg diltiazem hcl cap sr 12hr 120 mg diltiazem hcl cap sr 24hr 120 mg diltiazem hcl cap sr 24hr 180 mg diltiazem hcl cap sr 24hr 240 mg diltiazem hcl coated beads cap sr mg diltiazem hcl coated beads cap sr mg diltiazem hcl coated beads cap sr mg diltiazem hcl coated beads cap sr mg $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 24hr 120 $0 (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) QL (60 tabs / 30 days) QL (45 tabs / 30 days) QL (45 tabs / 30 days) 24hr 180 $0 (1) 24hr 240 $0 (1) 24hr 300 $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 32 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) diltiazem hcl coated beads cap sr 24hr 360 $0 (1) mg diltiazem hcl extended release beads cap sr$0 (1) 24hr 120 mg diltiazem hcl extended release beads cap sr$0 (1) 24hr 180 mg diltiazem hcl extended release beads cap sr$0 (1) 24hr 240 mg diltiazem hcl extended release beads cap sr$0 (1) 24hr 300 mg diltiazem hcl extended release beads cap sr$0 (1) 24hr 360 mg diltiazem hcl extended release beads cap sr$0 (1) 24hr 420 mg diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) $0 (1) diltiazem hcl iv soln 50 mg/10ml (5 mg/ml)$0 (1) diltiazem hcl iv soln 125 mg/25ml (5 $0 (1) mg/ml) diltiazem hcl tab 30 mg $0 (1) diltiazem hcl tab 60 mg $0 (1) diltiazem hcl tab 90 mg $0 (1) diltiazem hcl tab 120 mg $0 (1) diltzac cap 120mg/24 $0 (1) diltzac cap 180mg/24 $0 (1) diltzac cap 240mg/24 $0 (1) diltzac cap 300mg/24 $0 (1) felodipine tab sr 24hr 2.5 mg $0 (1) QL (30 tabs / 30 days) felodipine tab sr 24hr 5 mg $0 (1) QL (60 tabs / 30 days) felodipine tab sr 24hr 10 mg $0 (1) isradipine cap 2.5 mg $0 (1) isradipine cap 5 mg $0 (1) nicardipine hcl cap 20 mg $0 (1) nicardipine hcl cap 30 mg $0 (1) nifedical xl tab 30mg $0 (1) QL (30 tabs / 30 days) nifedical xl tab 60mg $0 (1) nifedipine tab sr 24hr 30 mg $0 (1) QL (60 tabs / 30 days) nifedipine tab sr 24hr 60 mg $0 (1) nifedipine tab sr 24hr 90 mg $0 (1) nifedipine tab sr 24hr osmotic release 30 $0 (1) QL (30 tabs / 30 days) mg nifedipine tab sr 24hr osmotic release 60 $0 (1) mg nifedipine tab sr 24hr osmotic release 90 $0 (1) mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not 33 available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid Drug Name (By Medical Condition) nimodipine cap 30 mg NYMALIZE SOL 60/20ML taztia xt cap 120mg/24 taztia xt cap 180mg/24 taztia xt cap 240mg/24 taztia xt cap 300mg/24 taztia xt cap 360mg/24 verapamil hcl cap sr 24hr 100 mg verapamil hcl cap sr 24hr 120 mg verapamil hcl cap sr 24hr 180 mg verapamil hcl cap sr 24hr 200 mg verapamil hcl cap sr 24hr 240 mg verapamil hcl cap sr 24hr 300 mg VERAPAMIL HCL CAP SR 24HR 360 MG verapamil hcl iv soln 2.5 mg/ml verapamil hcl tab 40 mg verapamil hcl tab 80 mg verapamil hcl tab 120 mg verapamil hcl tab cr 120 mg verapamil hcl tab cr 180 mg verapamil hcl tab cr 240 mg WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digitek tab 0.25mg $0 (1) digitek tab 0.125mg digoxin inj 0.25 mg/ml DIGOXIN ORAL SOLN 0.05 MG/ML $0 (1) $0 (1) $0 (1) digoxin tab 125 mcg (0.125 mg) digoxin tab 250 mcg (0.25 mg) $0 (1) $0 (1) LANOXIN TAB 0.25MG $0-$6.60 (2) LANOXIN TAB 0.125MG $0-$6.60 (2) PA; PA for age 65 or older QL (30 tabs / 30 days) PA; PA older QL (30 PA; PA older PA; PA older QL (30 for age 65 or tabs / 30 days) for age 65 or for age 65 or tabs / 30 days) DIRECT RENIN INHIBITORS/COMBINATIONS - DRUGS TO TREAT HEART CONDITIONS TEKAMLO TAB 150-5MG $0-$6.60 (2) QL (30 tabs / 30 days) TEKAMLO TAB 150-10MG $0-$6.60 (2) QL (30 tabs / 30 days) TEKTURNA HCT TAB 150-12.5 $0-$6.60 (2) QL (30 tabs / 30 days) TEKTURNA HCT TAB 150-25MG $0-$6.60 (2) QL (60 tabs / 30 days) TEKTURNA HCT TAB 300-12.5 $0-$6.60 (2) QL (30 tabs / 30 days) TEKTURNA HCT TAB 300-25MG $0-$6.60 (2) TEKTURNA TAB 150MG $0-$6.60 (2) QL (30 tabs / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not 34 available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid Drug Name (By Medical Condition) TEKTURNA TAB 300MG WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0-$6.60 (2) DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide cap sr 12hr 500 mg acetazolamide tab 125 mg acetazolamide tab 250 mg amiloride & hydrochlorothiazide tab 5-50 mg amiloride hcl tab 5 mg bumetanide inj 0.25 mg/ml bumetanide tab 0.5 mg bumetanide tab 1 mg bumetanide tab 2 mg chlorothiazide tab 250 mg chlorothiazide tab 500 mg chlorthalidone tab 25 mg chlorthalidone tab 50 mg DIURIL SUS 250/5ML DYRENIUM CAP 50MG DYRENIUM CAP 100MG EDECRIN TAB 25MG furosemide inj 10 mg/ml furosemide oral soln 10 mg/ml furosemide sol 8mg/ml furosemide tab 20 mg furosemide tab 40 mg furosemide tab 80 mg hydrochlorothiazide cap 12.5 mg hydrochlorothiazide tab 12.5 mg hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg indapamide tab 1.25 mg indapamide tab 2.5 mg methazolamide tab 25 mg methazolamide tab 50 mg methyclothiazide tab 5 mg metolazone tab 2.5 mg metolazone tab 5 mg metolazone tab 10 mg spironolactone & hydrochlorothiazide tab 25-25 mg torsemide inj 20mg/2ml torsemide inj 50mg/5ml $0 $0 $0 $0 (1) (1) (1) (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) (2) (2) (2) (2) $0 (1) $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 35 Drug Name (By Medical Condition) torsemide tab torsemide tab torsemide tab torsemide tab triamterene & 37.5-25 mg triamterene & 37.5-25 mg triamterene & 75-50 mg 5 mg 10 mg 20 mg 100 mg hydrochlorothiazide cap WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) hydrochlorothiazide tab $0 (1) hydrochlorothiazide tab $0 (1) MISCELLANEOUS clonidine hcl tab 0.1 mg $0 (1) clonidine hcl tab 0.2 mg $0 (1) clonidine hcl tab 0.3 mg $0 (1) clonidine hcl td patch weekly 0.1 mg/24hr $0 (1) clonidine hcl td patch weekly 0.2 mg/24hr $0 (1) clonidine hcl td patch weekly 0.3 mg/24hr $0 (1) DEMSER CAP 250MG $0-$6.60 (2) hydralazine hcl inj 20 mg/ml $0 (1) hydralazine hcl tab 10 mg $0 (1) hydralazine hcl tab 25 mg $0 (1) hydralazine hcl tab 50 mg $0 (1) hydralazine hcl tab 100 mg $0 (1) midodrine hcl tab 2.5 mg $0 (1) midodrine hcl tab 5 mg $0 (1) midodrine hcl tab 10 mg $0 (1) minoxidil tab 2.5 mg $0 (1) minoxidil tab 10 mg $0 (1) RANEXA TAB 500MG $0-$6.60 (2) RANEXA TAB 1000MG $0-$6.60 (2) NITRATES - DRUGS TO TREAT HEART CONDITIONS isosorbide dinitrate tab isosorbide dinitrate tab isosorbide dinitrate tab isosorbide dinitrate tab isosorbide dinitrate tab isosorbide mononitrate isosorbide mononitrate isosorbide mononitrate isosorbide mononitrate isosorbide mononitrate minitran dis 0.1mg/hr 5 mg $0 10 mg $0 20 mg $0 30 mg $0 cr 40 mg $0 tab 10 mg $0 tab 20 mg $0 tab sr 24hr 30 mg $0 tab sr 24hr 60 mg $0 tab sr 24hr 120 mg$0 $0 (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 36 Drug Name (By Medical Condition) minitran dis 0.2mg/hr minitran dis 0.4mg/hr minitran dis 0.6mg/hr nitro-bid oin 2% NITRO-DUR DIS 0.3MG/HR NITRO-DUR DIS 0.8MG/HR nitroglycerin td patch 24hr 0.1 mg/hr nitroglycerin td patch 24hr 0.2 mg/hr nitroglycerin td patch 24hr 0.4 mg/hr nitroglycerin td patch 24hr 0.6 mg/hr NITROLINGUAL SPR PUMPSPRA NITROSTAT SUB 0.3MG NITROSTAT SUB 0.4MG NITROSTAT SUB 0.6MG WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION ADCIRCA TAB 20MG $0-$6.60 (2) QL (60 tabs / 30 days), NM, PA ADEMPAS TAB 0.5MG $0-$6.60 (2) QL (90 tabs / 30 days), NM, PA ADEMPAS TAB 1.5MG $0-$6.60 (2) QL (90 tabs / 30 days), NM, PA ADEMPAS TAB 1MG $0-$6.60 (2) QL (90 tabs / 30 days), NM, PA ADEMPAS TAB 2.5MG $0-$6.60 (2) QL (90 tabs / 30 days), NM, PA ADEMPAS TAB 2MG $0-$6.60 (2) QL (90 tabs / 30 days), NM, PA LETAIRIS TAB 5MG $0-$6.60 (2) QL (30 tabs / 30 days), NM, LA, PA LETAIRIS TAB 10MG $0-$6.60 (2) QL (30 tabs / 30 days), NM, LA, PA REMODULIN INJ 1MG/ML $0-$6.60 (2) B/D, NM, LA REMODULIN INJ 2.5MG/ML $0-$6.60 (2) B/D, NM, LA REMODULIN INJ 5MG/ML $0-$6.60 (2) B/D, NM, LA REMODULIN INJ 10MG/ML $0-$6.60 (2) B/D, NM, LA REVATIO SUS 10MG/ML $0-$6.60 (2) QL (2 bottles / 30 days), NM, PA sildenafil citrate tab 20 mg $0-$6.60 (2) QL (90 tabs / 30 days), NM, PA TRACLEER TAB 62.5MG $0-$6.60 (2) QL (120 tabs / 30 days), NM, LA, PA TRACLEER TAB 125MG $0-$6.60 (2) QL (60 tabs / 30 days), NM, LA, PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not 37 available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY alprazolam con 1 mg/ml alprazolam tab 0.5 mg alprazolam tab 0.25 mg alprazolam tab 1 mg alprazolam tab 2 mg buspirone hcl tab 5 mg buspirone hcl tab 7.5 mg buspirone hcl tab 10 mg buspirone hcl tab 15 mg buspirone hcl tab 30 mg fluvoxamine maleate tab 25 mg fluvoxamine maleate tab 50 mg fluvoxamine maleate tab 100 mg lorazepam con 2mg/ml lorazepam inj 2 mg/ml lorazepam inj 4 mg/ml lorazepam tab 0.5 mg lorazepam tab 1 mg lorazepam tab 2 mg $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) QL QL QL QL QL (300 (240 (480 (120 (150 mL / 30 days) tabs / 30 days) tabs / 30 days) tabs / 30 days) tabs / 30 days) QL (45 tabs / 30 days) QL (45 tabs / 30 days) QL (150 mL / 30 days) QL (150 tabs / 30 days) QL (150 tabs / 30 days) QL (150 tabs / 30 days) ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM TAB 200MG $0-$6.60 (2) QL (180 tabs / 30 days) APTIOM TAB 400MG $0-$6.60 (2) QL (90 tabs / 30 days) APTIOM TAB 600MG $0-$6.60 (2) QL (60 tabs / 30 days) APTIOM TAB 800MG $0-$6.60 (2) QL (30 tabs / 30 days) BANZEL SUS 40MG/ML $0-$6.60 (2) PA BANZEL TAB 200MG $0-$6.60 (2) PA BANZEL TAB 400MG $0-$6.60 (2) PA carbamazepine cap sr 12hr 100 mg $0 (1) carbamazepine cap sr 12hr 200 mg $0 (1) carbamazepine cap sr 12hr 300 mg $0 (1) carbamazepine chew tab 100 mg $0 (1) carbamazepine susp 100 mg/5ml $0 (1) carbamazepine tab 200 mg $0 (1) carbamazepine tab sr 12hr 200 mg $0 (1) carbamazepine tab sr 12hr 400 mg $0 (1) CELONTIN CAP 300MG $0-$6.60 (2) clonazepam orally disintegrating tab 0.5 $0 (1) QL (1200 tabs / 30 days) mg clonazepam orally disintegrating tab 0.25 $0 (1) QL (2400 tabs / 30 days) mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not 38 available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) clonazepam orally disintegrating tab 0.125 $0 (1) mg clonazepam orally disintegrating tab 1 mg $0 (1) clonazepam orally disintegrating tab 2 mg $0 (1) clonazepam tab 0.5 mg $0 (1) clonazepam tab 1 mg $0 (1) clonazepam tab 2 mg $0 (1) clorazepate dipotassium tab 3.75 mg $0 (1) clorazepate dipotassium tab 7.5 mg $0 (1) clorazepate dipotassium tab 15 mg $0 (1) diazepam con 5mg/ml $0 (1) diazepam inj 5 mg/ml $0 (1) DIAZEPAM RECTAL GEL DELIVERY SYSTEM $0 (1) 2.5 MG DIAZEPAM RECTAL GEL DELIVERY SYSTEM $0 (1) 10 MG DIAZEPAM RECTAL GEL DELIVERY SYSTEM $0 (1) 20 MG diazepam soln 1 mg/ml $0 (1) diazepam tab 2 mg $0 (1) diazepam tab 5 mg $0 (1) diazepam tab 10 mg $0 (1) dilantin cap 30mg $0-$6.60 dilantin cap 100mg $0-$6.60 dilantin chw 50mg $0-$6.60 DILANTIN-125 SUS 125/5ML $0-$6.60 divalproex sodium cap sprinkle 125 mg $0 (1) divalproex sodium tab delayed release 125 $0 (1) mg divalproex sodium tab delayed release 250 $0 (1) mg divalproex sodium tab delayed release 500 $0 (1) mg divalproex sodium tab sr 24 hr 250 mg $0 (1) divalproex sodium tab sr 24 hr 500 mg $0 (1) epitol tab 200mg $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (4800 tabs / 30 days) QL QL QL QL QL QL PA QL PA QL PA QL PA (600 tabs / 30 days) (300 tabs / 30 days) (1200 tabs / 30 days) (600 tabs / 30 days) (300 tabs / 30 days) (120 tabs / 30 days), QL PA QL PA QL PA QL PA (1200 mL / 30 days), (120 tabs / 30 days), (180 tabs / 30 days), (240 mL / 30 days), (120 tabs / 30 days), (120 tabs / 30 days), (120 tabs / 30 days), (2) (2) (2) (2) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 39 Drug Name (By Medical Condition) ethosuximide cap 250 mg ethosuximide soln 250 mg/5ml felbamate susp 600 mg/5ml felbamate tab 400 mg felbamate tab 600 mg FYCOMPA TAB 2MG WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0 (1) $0-$6.60 (2) $0 (1) $0-$6.60 (2) $0-$6.60 (2) FYCOMPA TAB 4MG $0-$6.60 (2) FYCOMPA TAB 6MG $0-$6.60 (2) FYCOMPA TAB 8MG $0-$6.60 (2) FYCOMPA TAB 10MG $0-$6.60 (2) FYCOMPA TAB 12MG $0-$6.60 (2) gabapentin cap 100 mg $0 (1) gabapentin cap 300 mg $0 (1) gabapentin cap 400 mg $0 (1) gabapentin oral soln 250 mg/5ml $0 (1) gabapentin tab 600 mg $0 (1) gabapentin tab 800 mg $0 (1) GABITRIL TAB 12MG $0-$6.60 GABITRIL TAB 16MG $0-$6.60 lamotrigine tab 25 mg $0 (1) lamotrigine tab 100 mg $0 (1) lamotrigine tab 150 mg $0 (1) lamotrigine tab 200 mg $0 (1) lamotrigine tab chewable dispersible 5 mg $0 (1) lamotrigine tab chewable dispersible 25 mg$0 (1) lamotrigine tab sr 24hr 25 mg $0 (1) lamotrigine tab sr 24hr 50 mg $0 (1) lamotrigine tab sr 24hr 100 mg $0 (1) lamotrigine tab sr 24hr 200 mg $0 (1) lamotrigine tab sr 24hr 250 mg $0 (1) lamotrigine tab sr 24hr 300 mg $0 (1) LEVETIRACETA INJ 5MG/ML $0-$6.60 LEVETIRACETA INJ 10MG/ML $0-$6.60 LEVETIRACETA INJ 15MG/ML $0-$6.60 levetiracetam inj 500 mg/5ml (100 mg/ml)$0 (1) levetiracetam oral soln 100 mg/ml $0 (1) levetiracetam tab 250 mg $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (180 tabs / 30 days), PA QL (90 tabs / 30 days), PA QL (60 tabs / 30 days), PA QL (30 tabs / 30 days), PA QL (30 tabs / 30 days), PA QL (30 tabs / 30 days), PA QL (1080 caps / 30 days) QL (360 caps / 30 days) QL (270 caps / 30 days) QL (2160 mL / 30 days) QL (180 tabs / 30 days) QL (120 tabs / 30 days) (2) (2) (2) (2) (2) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 40 Drug Name (By Medical Condition) levetiracetam tab 500 mg levetiracetam tab 750 mg levetiracetam tab 1000 mg levetiracetam tab sr 24hr 500 mg levetiracetam tab sr 24hr 750 mg LYRICA CAP 25MG LYRICA CAP 50MG LYRICA CAP 75MG LYRICA CAP 100MG LYRICA CAP 150MG LYRICA CAP 200MG LYRICA CAP 225MG LYRICA CAP 300MG LYRICA SOL 20MG/ML ONFI SUS 2.5MG/ML ONFI TAB 10MG ONFI TAB 20MG oxcarbazepine susp 300 mg/5ml (60 mg/ml) oxcarbazepine tab 150 mg oxcarbazepine tab 300 mg oxcarbazepine tab 600 mg PEGANONE TAB 250MG PHENOBARB INJ 65MG/ML WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) phenobarbital elixir 20 mg/5ml $0-$6.60 (2) phenobarbital sodium inj 130 mg/ml $0-$6.60 (2) phenobarbital tab 15 mg $0-$6.60 (2) phenobarbital tab 16.2 mg $0-$6.60 (2) phenobarbital tab 30 mg $0-$6.60 (2) phenobarbital tab 32.4 mg $0-$6.60 (2) phenobarbital tab 60 mg $0-$6.60 (2) phenobarbital tab 64.8 mg $0-$6.60 (2) phenobarbital tab 97.2 mg $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL QL QL QL QL QL QL QL QL PA PA PA (120 caps / 30 days) (120 caps / 30 days) (120 caps / 30 days) (120 caps / 30 days) (120 caps / 30 days) (90 caps / 30 days) (60 caps / 30 days) (60 caps / 30 days) (946 mL / 30 days) PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 41 Drug Name (By Medical Condition) phenobarbital tab 100 mg WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) phenytek cap 200mg phenytek cap 300mg phenytoin chew tab 50 mg phenytoin sodium extended cap 100 mg phenytoin sodium extended cap 200 mg phenytoin sodium extended cap 300 mg phenytoin sodium inj 50 mg/ml phenytoin susp 125 mg/5ml POTIGA TAB 50MG POTIGA TAB 200MG POTIGA TAB 300MG POTIGA TAB 400MG primidone tab 50 mg primidone tab 250 mg SABRIL POW 500MG $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0-$6.60 SABRIL TAB 500MG $0-$6.60 (2) TEGRETOL SUS 100/5ML $0-$6.60 TEGRETOL TAB 200MG $0-$6.60 TEGRETOL-XR TAB 100MG $0-$6.60 TEGRETOL-XR TAB 200MG $0-$6.60 TEGRETOL-XR TAB 400MG $0-$6.60 tiagabine hcl tab 2 mg $0 (1) tiagabine hcl tab 4 mg $0 (1) topiramate sprinkle cap 15 mg $0 (1) topiramate sprinkle cap 25 mg $0 (1) topiramate tab 25 mg $0 (1) topiramate tab 50 mg $0 (1) topiramate tab 100 mg $0 (1) topiramate tab 200 mg $0 (1) valproate sodium inj 100 mg/ml $0 (1) valproate sodium syrup 250 mg/5ml (base $0 (1) equiv) valproic acid cap 250 mg $0 (1) VIMPAT INJ 200MG/20 $0-$6.60 VIMPAT SOL 10MG/ML $0-$6.60 VIMPAT TAB 50MG $0-$6.60 VIMPAT TAB 100MG $0-$6.60 VIMPAT TAB 150MG $0-$6.60 VIMPAT TAB 200MG $0-$6.60 NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE PA; PA for age 65 or older (2) (2) (2) (2) (2) (2) (2) QL (180 tabs / 30 days) QL (90 tabs / 30 days) QL (90 tabs / 30 days) QL (180 packets / 30 days), NM, LA, PA QL (180 tabs / 30 days), NM, LA, PA (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) QL QL QL QL QL (1200 mL / 30 days) (180 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 42 Drug Name (By Medical Condition) zonisamide cap 25 mg zonisamide cap 50 mg zonisamide cap 100 mg WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0 (1) $0 (1) ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride orally disintegrating tab 5 mg donepezil hydrochloride orally disintegrating tab 10 mg donepezil hydrochloride tab 5 mg donepezil hydrochloride tab 10 mg donepezil hydrochloride tab 23 mg EXELON DIS 4.6MG/24 $0 (1) EXELON DIS 9.5MG/24 $0-$6.60 (2) EXELON DIS 13.3/24 $0-$6.60 (2) QL (30 tabs / 30 days) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) QL (30 tabs / 30 days) QL (30 days) QL (30 days) QL (30 days) QL (30 patches / 30 patches / 30 patches / 30 galantamine hydrobromide cap sr 24hr 8 $0 (1) caps / 30 days) mg galantamine hydrobromide cap sr 24hr 16 $0 (1) QL (30 caps / 30 days) mg galantamine hydrobromide cap sr 24hr 24 $0 (1) mg galantamine hydrobromide oral soln 4 $0 (1) mg/ml galantamine hydrobromide tab 4 mg $0 (1) QL (180 tabs / 30 days) galantamine hydrobromide tab 8 mg $0 (1) QL (90 tabs / 30 days) galantamine hydrobromide tab 12 mg $0 (1) memantine hcl tab 5 mg $0 (1) PA; PA if <30 yr MEMANTINE HCL TAB 10 MG $0 (1) PA; PA if <30 yr NAMENDA SOL 10MG/5ML $0-$6.60 (2) PA; PA if <30 yr NAMENDA TAB 5MG $0-$6.60 (2) PA; PA if <30 yr NAMENDA TAB 10MG $0-$6.60 (2) PA; PA if <30 yr NAMENDA XR CAP 7MG $0-$6.60 (2) PA; PA if <30 yr NAMENDA XR CAP 14MG $0-$6.60 (2) PA; PA if <30 yr NAMENDA XR CAP 21MG $0-$6.60 (2) PA; PA if <30 yr NAMENDA XR CAP 28MG $0-$6.60 (2) PA; PA if <30 yr NAMENDA XR CAP TITRATIO $0-$6.60 (2) PA; PA if <30 yr NAMZARIC CAP 14-10MG $0-$6.60 (2) NAMZARIC CAP 28-10MG $0-$6.60 (2) rivastigmine tartrate cap 1.5 mg $0 (1) rivastigmine tartrate cap 3 mg $0 (1) rivastigmine tartrate cap 4.5 mg $0 (1) rivastigmine tartrate cap 6 mg $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not 43 available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid Drug Name (By Medical Condition) RIVASTIGMINE TD PATCH 24HR 4.6 MG/24HR RIVASTIGMINE TD PATCH 24HR 9.5 MG/24HR RIVASTIGMINE TD PATCH 24HR 13.3 MG/24HR WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0 (1) $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (30 patches / 30 days) QL (30 patches / 30 days) QL (30 patches / 30 days) ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION amitriptyline hcl tab 10 mg $0-$6.60 (2) amitriptyline hcl tab 25 mg $0-$6.60 (2) amitriptyline hcl tab 50 mg $0-$6.60 (2) amitriptyline hcl tab 75 mg $0-$6.60 (2) amitriptyline hcl tab 100 mg $0-$6.60 (2) amitriptyline hcl tab 150 mg $0-$6.60 (2) amoxapine tab 25 mg amoxapine tab 50 mg amoxapine tab 100 mg amoxapine tab 150 mg BRINTELLIX TAB 5MG BRINTELLIX TAB 10MG BRINTELLIX TAB 20MG bupropion hcl tab 75 mg bupropion hcl tab 100 mg bupropion hcl tab sr 12hr 100 mg bupropion hcl tab sr 12hr 150 mg bupropion hcl tab sr 12hr 200 mg bupropion hcl tab sr 24hr 150 mg bupropion hcl tab sr 24hr 300 mg citalopram hydrobromide oral soln 10 mg/5ml citalopram hydrobromide tab 10 mg (base equiv) citalopram hydrobromide tab 20 mg (base equiv) citalopram hydrobromide tab 40 mg (base equiv) clomipramine hcl cap 25 mg $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or QL (120 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (90 tabs / 30 days) QL (30 tabs / 30 days) $0 (1) QL (45 tabs / 30 days) $0 (1) QL (45 tabs / 30 days) $0 (1) QL (30 tabs / 30 days) $0-$6.60 (2) PA; PA for age 65 or older PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 44 Drug Name (By Medical Condition) clomipramine hcl cap 50 mg WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) clomipramine hcl cap 75 mg $0-$6.60 (2) desipramine hcl tab 10 mg desipramine hcl tab 25 mg desipramine hcl tab 50 mg desipramine hcl tab 75 mg desipramine hcl tab 100 mg desipramine hcl tab 150 mg doxepin hcl cap 10 mg $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) doxepin hcl cap 25 mg $0-$6.60 (2) doxepin hcl cap 50 mg $0-$6.60 (2) doxepin hcl cap 75 mg $0-$6.60 (2) doxepin hcl cap 100 mg $0-$6.60 (2) doxepin hcl cap 150 mg $0-$6.60 (2) doxepin hcl conc 10 mg/ml $0-$6.60 (2) duloxetine hcl enteric coated pellets cap 20$0 (1) mg duloxetine hcl enteric coated pellets cap 30$0 (1) mg duloxetine hcl enteric coated pellets cap 60$0 (1) mg EMSAM DIS 6MG/24HR $0-$6.60 (2) EMSAM DIS 9MG/24HR $0-$6.60 (2) EMSAM DIS 12MG/24H $0-$6.60 (2) escitalopram oxalate soln 5 mg/5ml (base $0 (1) equiv) escitalopram oxalate tab 5 mg (base equiv)$0 (1) escitalopram oxalate tab 10 mg (base $0 (1) equiv) escitalopram oxalate tab 20 mg (base $0 (1) equiv) FETZIMA CAP 20MG $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE PA; PA for age 65 or older PA; PA for age 65 or older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older QL (60 for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or caps / 30 days) QL (60 caps / 30 days) QL (60 caps / 30 days) QL (30 patches / 30 days), PA QL (30 patches / 30 days), PA QL (30 patches / 30 days), PA QL (600 mL / 30 days) QL (45 tabs / 30 days) QL (45 tabs / 30 days) QL (60 tabs / 30 days) QL (180 caps / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 45 Drug Name (By Medical Condition) FETZIMA CAP 40MG FETZIMA CAP 80MG FETZIMA CAP 120MG FETZIMA CAP TITRATIO fluoxetine hcl cap 10 mg fluoxetine hcl cap 20 mg fluoxetine hcl cap 40 mg fluoxetine hcl solution 20 mg/5ml fluoxetine hcl tab 10 mg fluoxetine hcl tab 20 mg imipramine hcl tab 10 mg WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) imipramine hcl tab 25 mg $0-$6.60 (2) imipramine hcl tab 50 mg $0-$6.60 (2) maprotiline hcl tab 25 mg $0 (1) maprotiline hcl tab 50 mg $0 (1) maprotiline hcl tab 75 mg $0 (1) MARPLAN TAB 10MG $0-$6.60 (2) mirtazapine orally disintegrating tab 15 mg$0 (1) mirtazapine orally disintegrating tab 30 mg$0 (1) mirtazapine orally disintegrating tab 45 mg$0 (1) mirtazapine tab 7.5 mg $0 (1) mirtazapine tab 15 mg $0 (1) mirtazapine tab 30 mg $0 (1) mirtazapine tab 45 mg $0 (1) nefazodone hcl tab 50 mg $0 (1) nefazodone hcl tab 100 mg $0 (1) nefazodone hcl tab 150 mg $0 (1) nefazodone hcl tab 200 mg $0 (1) nefazodone hcl tab 250 mg $0 (1) nortriptyline hcl cap 10 mg $0 (1) nortriptyline hcl cap 25 mg $0 (1) nortriptyline hcl cap 50 mg $0 (1) nortriptyline hcl cap 75 mg $0 (1) nortriptyline hcl soln 10 mg/5ml $0 (1) paroxetine hcl tab 10 mg $0 (1) paroxetine hcl tab 20 mg $0 (1) paroxetine hcl tab 30 mg $0 (1) paroxetine hcl tab 40 mg $0 (1) PAXIL SUS 10MG/5ML $0-$6.60 (2) phenelzine sulfate tab 15 mg $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (90 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days) QL (120 caps / 30 days) QL (45 tabs / 30 days) PA; PA for age 65 or older PA; PA for age 65 or older PA; PA for age 65 or older QL (180 tabs / 30 days) QL (30 tabs / 30 days) QL (45 tabs / 30 days) QL (45 tabs / 30 days) QL QL QL QL QL (45 tabs (45 tabs (60 tabs (45 tabs (900 mL / / / / / 30 30 30 30 30 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid days) days) days) days) days) 46 Drug Name (By Medical Condition) PRISTIQ TAB 25MG PRISTIQ TAB 50MG PRISTIQ TAB 100MG protriptyline hcl tab 5 mg protriptyline hcl tab 10 mg sertraline hcl oral conc 20 mg/ml sertraline hcl tab 25 mg sertraline hcl tab 50 mg sertraline hcl tab 100 mg SURMONTIL CAP 25MG WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) SURMONTIL CAP 50MG $0-$6.60 (2) SURMONTIL CAP 100MG $0-$6.60 (2) tranylcypromine sulfate tab 10 mg trazodone hcl tab 50 mg trazodone hcl tab 100 mg trazodone hcl tab 150 mg venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) venlafaxine hcl cap sr 24hr 75 mg (base equivalent) venlafaxine hcl cap sr 24hr 150 mg (base equivalent) venlafaxine hcl tab 25 mg venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg venlafaxine hcl tab 100 mg VIIBRYD KIT VIIBRYD KIT STARTER VIIBRYD TAB 10MG VIIBRYD TAB 20MG VIIBRYD TAB 40MG $0 $0 $0 $0 $0 NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (45 tabs / 30 days) QL (45 tabs / 30 days) QL (240 caps / 30 days), PA; PA for age 65 or older QL (120 caps / 30 days), PA; PA for age 65 or older QL (60 caps / 30 days), PA; PA for age 65 or older (1) (1) (1) (1) (1) QL (30 caps / 30 days) $0 (1) QL (30 caps / 30 days) $0 (1) QL (60 caps / 30 days) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) (2) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml amantadine hcl tab 100 mg $0 (1) $0 (1) $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 47 Drug Name (By Medical Condition) APOKYN INJ 10MG/ML AZILECT TAB 0.5MG AZILECT TAB 1MG benztropine mesylate inj 1 mg/ml benztropine mesylate tab 0.5 mg WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0-$6.60 (2) benztropine mesylate tab 1 mg $0-$6.60 (2) benztropine mesylate tab 2 mg $0-$6.60 (2) bromocriptine mesylate cap 5 mg bromocriptine mesylate tab 2.5 mg carbidopa & levodopa orally disintegrating tab 10-100 mg carbidopa & levodopa orally disintegrating tab 25-100 mg carbidopa & levodopa orally disintegrating tab 25-250 mg carbidopa & levodopa tab 10-100 mg carbidopa & levodopa tab 25-100 mg carbidopa & levodopa tab 25-250 mg carbidopa & levodopa tab cr 25-100 mg carbidopa & levodopa tab cr 50-200 mg CARBIDOPA-LEVODOPA-ENTACAPONE TABS 12.5-50-200 MG CARBIDOPA-LEVODOPA-ENTACAPONE TABS 18.75-75-200 MG CARBIDOPA-LEVODOPA-ENTACAPONE TABS 25-100-200 MG CARBIDOPA-LEVODOPA-ENTACAPONE TABS 31.25-125-200 MG CARBIDOPA-LEVODOPA-ENTACAPONE TABS 37.5-150-200 MG CARBIDOPA-LEVODOPA-ENTACAPONE TABS 50-200-200 MG entacapone tab 200 mg NEUPRO DIS 1MG/24HR NEUPRO DIS 2MG/24HR NEUPRO DIS 3MG/24HR NEUPRO DIS 4MG/24HR NEUPRO DIS 6MG/24HR NEUPRO DIS 8MG/24HR pramipexole dihydrochloride tab 0.5 mg pramipexole dihydrochloride tab 0.25 mg $0 (1) $0 (1) $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE NM, LA, PA PA; PA for age 65 or older PA; PA for age 65 or older PA; PA for age 65 or older $0 (1) $0 (1) $0 $0 $0 $0 $0 $0 (1) (1) (1) (1) (1) (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) (2) (2) (2) (2) (2) (2) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 48 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) pramipexole dihydrochloride tab 0.75 mg $0 (1) pramipexole dihydrochloride tab 0.125 mg $0 (1) pramipexole dihydrochloride tab 1 mg $0 (1) pramipexole dihydrochloride tab 1.5 mg $0 (1) ropinirole hydrochloride tab 0.5 mg $0 (1) ropinirole hydrochloride tab 0.25 mg $0 (1) ropinirole hydrochloride tab 1 mg $0 (1) ropinirole hydrochloride tab 2 mg $0 (1) ropinirole hydrochloride tab 3 mg $0 (1) ropinirole hydrochloride tab 4 mg $0 (1) ropinirole hydrochloride tab 5 mg $0 (1) selegiline hcl cap 5 mg $0 (1) selegiline hcl tab 5 mg $0 (1) trihexyphenidyl hcl elixir 0.4 mg/ml $0-$6.60 (2) trihexyphenidyl hcl tab 2 mg $0-$6.60 (2) trihexyphenidyl hcl tab 5 mg $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE PA; PA for age 65 or older PA; PA for age 65 or older PA; PA for age 65 or older ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES ABILIFY DISC TAB 10MG ABILIFY DISC TAB 15MG ABILIFY INJ 9.75MG ABILIFY MAIN INJ 300MG ABILIFY MAIN INJ 300MG ABILIFY MAIN INJ 400MG ABILIFY MAIN INJ 400MG ABILIFY SOL 1MG/ML ABILIFY TAB 2MG ABILIFY TAB 5MG ABILIFY TAB 10MG ABILIFY TAB 15MG ABILIFY TAB 20MG ABILIFY TAB 30MG aripiprazole oral solution 1 mg/ml aripiprazole tab 2 mg aripiprazole tab 5 mg aripiprazole tab 10 mg aripiprazole tab 15 mg aripiprazole tab 20 mg aripiprazole tab 30 mg chlorpromaz inj 50mg/2ml chlorpromazine hcl tab 10 mg $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) QL QL QL QL QL QL QL (60 tabs / 30 days) (60 tabs / 30 days) (4 mL / 1 day) (1 syringe / 28 days) (1 vial / 28 days) (1 syringe / 28 days) (1 vial / 28 days) QL QL QL QL QL QL (30 (30 (30 (30 (30 (30 tabs tabs tabs tabs tabs tabs / / / / / / 30 30 30 30 30 30 days) days) days) days) days) days) QL QL QL QL QL QL (30 (30 (30 (30 (30 (30 tabs tabs tabs tabs tabs tabs / / / / / / 30 30 30 30 30 30 days) days) days) days) days) days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 49 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) chlorpromazine hcl tab 25 mg $0 (1) chlorpromazine hcl tab 50 mg $0 (1) chlorpromazine hcl tab 100 mg $0 (1) chlorpromazine hcl tab 200 mg $0 (1) CLOZAPINE ORALLY DISINTEGRATING TAB$0 (1) 12.5 MG CLOZAPINE ORALLY DISINTEGRATING TAB$0 (1) 25 MG CLOZAPINE ORALLY DISINTEGRATING TAB$0 (1) 100 MG CLOZAPINE ORALLY DISINTEGRATING TAB$0 (1) 150 MG CLOZAPINE ORALLY DISINTEGRATING TAB$0 (1) 200 MG clozapine tab 25 mg $0 (1) clozapine tab 50 mg $0 (1) clozapine tab 100 mg $0 (1) clozapine tab 200 mg $0 (1) FANAPT PAK $0-$6.60 (2) FANAPT TAB 1MG $0-$6.60 (2) FANAPT TAB 2MG $0-$6.60 (2) FANAPT TAB 4MG $0-$6.60 (2) FANAPT TAB 6MG $0-$6.60 (2) FANAPT TAB 8MG $0-$6.60 (2) FANAPT TAB 10MG $0-$6.60 (2) FANAPT TAB 12MG $0-$6.60 (2) FAZACLO TAB 12.5/ODT FAZACLO TAB 25MG ODT FAZACLO TAB 100/ODT $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) FAZACLO TAB 150MG $0-$6.60 (2) FAZACLO TAB 200MG $0-$6.60 (2) fluphenazine decanoate inj 25 mg/ml fluphenazine hcl elixir 2.5 mg/5ml fluphenazine hcl inj 2.5 mg/ml $0 (1) $0 (1) $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE PA PA QL (270 tabs / 30 days), PA QL (180 tabs / 30 days), PA QL (135 tabs / 30 days), PA QL QL ST QL ST QL ST QL ST QL ST QL ST QL ST QL ST PA PA QL PA QL PA QL PA (270 tabs / 30 days) (135 tabs / 30 days) (60 tabs / 30 days), (60 tabs / 30 days), (60 tabs / 30 days), (60 tabs / 30 days), (60 tabs / 30 days), (60 tabs / 30 days), (60 tabs / 30 days), (270 tabs / 30 days), (180 tabs / 30 days), (135 tabs / 30 days), PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 50 Drug Name (By Medical Condition) fluphenazine hcl oral conc 5 mg/ml fluphenazine hcl tab 1 mg fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg fluphenazine hcl tab 10 mg GEODON INJ 20MG haloperidol decanoate im soln 50 mg/ml haloperidol decanoate im soln 100 mg/ml haloperidol lactate inj 5 mg/ml haloperidol lactate oral conc 2 mg/ml haloperidol tab 0.5 mg haloperidol tab 1 mg haloperidol tab 2 mg haloperidol tab 5 mg haloperidol tab 10 mg haloperidol tab 20 mg INVEGA SUST INJ 39/0.25 INVEGA SUST INJ 78/0.5ML INVEGA SUST INJ 117/0.75 INVEGA SUST INJ 156MG/ML INVEGA SUST INJ 234/1.5 INVEGA TAB 1.5MG INVEGA TAB 3MG INVEGA TAB 6MG INVEGA TAB 9MG LATUDA TAB 20MG LATUDA TAB 40MG LATUDA TAB 60MG LATUDA TAB 80MG LATUDA TAB 120MG loxapine succinate cap 5 mg loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 50 mg olanzapine for im inj 10 mg olanzapine orally disintegrating tab 5 mg olanzapine orally disintegrating tab 10 mg olanzapine orally disintegrating tab 15 mg olanzapine orally disintegrating tab 20 mg olanzapine tab 2.5 mg olanzapine tab 5 mg olanzapine tab 7.5 mg olanzapine tab 10 mg WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (6 mL / 3 days) QL (1 injection / 28 days) QL (1 injection / 28 days) QL (1 injection / 28 days) QL (1 injection / 28 days) QL (1 injection / 28 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (240 tabs / 30 days) QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL QL QL QL QL QL QL QL QL (3 vials / 1 day) (30 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (60 tabs / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 51 Drug Name (By Medical Condition) olanzapine tab 15 mg olanzapine tab 20 mg ORAP TAB 1MG ORAP TAB 2MG perphenazine tab 2 mg perphenazine tab 4 mg perphenazine tab 8 mg perphenazine tab 16 mg quetiapine fumarate tab 25 mg quetiapine fumarate tab 50 mg quetiapine fumarate tab 100 mg quetiapine fumarate tab 200 mg quetiapine fumarate tab 300 mg quetiapine fumarate tab 400 mg REXULTI TAB 0.5MG WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) REXULTI TAB 0.25MG $0-$6.60 (2) REXULTI TAB 1MG $0-$6.60 (2) REXULTI TAB 2MG $0-$6.60 (2) REXULTI TAB 3MG $0-$6.60 (2) REXULTI TAB 4MG $0-$6.60 (2) RISPERDAL INJ 12.5MG $0-$6.60 (2) RISPERDAL INJ 25MG $0-$6.60 (2) RISPERDAL INJ 37.5MG $0-$6.60 (2) RISPERDAL INJ 50MG $0-$6.60 (2) risperidone risperidone mg risperidone risperidone risperidone risperidone risperidone risperidone risperidone NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (60 tabs / 30 days) QL (60 tabs / 30 days) orally disintegrating tab 0.5 mg$0 (1) orally disintegrating tab 0.25 $0 (1) QL (90 tabs / 30 days) QL (90 tabs / 30 days) QL (90 tabs / 30 days) QL (90 tabs / 30 days) QL (90 tabs / 30 days) QL (90 tabs / 30 days) QL (180 tabs / 30 days), ST QL (360 tabs / 30 days), ST QL (90 tabs / 30 days), ST QL (60 tabs / 30 days), ST QL (30 tabs / 30 days), ST QL (30 tabs / 30 days), ST QL (2 injections / 28 days) QL (2 injections / 28 days) QL (2 injections / 28 days) QL (2 injections / 28 days) QL (90 tabs / 30 days) QL (90 tabs / 30 days) orally disintegrating orally disintegrating orally disintegrating orally disintegrating soln 1 mg/ml tab 0.5 mg tab 0.25 mg QL QL QL QL QL QL QL tab tab tab tab 1 2 3 4 mg mg mg mg $0 $0 $0 $0 $0 $0 $0 (1) (1) (1) (1) (1) (1) (1) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (120 tabs / 30 days) (240 mL / 30 days) (90 tabs / 30 days) (90 tabs / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 52 Drug Name (By Medical Condition) risperidone tab 1 mg risperidone tab 2 mg risperidone tab 3 mg risperidone tab 4 mg SAPHRIS SUB 2.5MG SAPHRIS SUB 5MG SAPHRIS SUB 10MG SEROQUEL XR TAB 50MG SEROQUEL XR TAB 150MG SEROQUEL XR TAB 200MG SEROQUEL XR TAB 300MG SEROQUEL XR TAB 400MG thioridazine hcl tab 10 mg WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) thioridazine hcl tab 25 mg $0-$6.60 (2) thioridazine hcl tab 50 mg $0-$6.60 (2) thioridazine hcl tab 100 mg $0-$6.60 (2) thiothixene cap 1 mg thiothixene cap 2 mg thiothixene cap 5 mg thiothixene cap 10 mg trifluoperazine hcl tab 1 mg trifluoperazine hcl tab 2 mg trifluoperazine hcl tab 5 mg trifluoperazine hcl tab 10 mg VERSACLOZ SUS 50MG/ML $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) ziprasidone hcl ziprasidone hcl ziprasidone hcl ziprasidone hcl ZYPREXA RELP ZYPREXA RELP ZYPREXA RELP $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) cap 20 mg cap 40 mg cap 60 mg cap 80 mg INJ 210MG INJ 300MG INJ 405MG NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (120 tabs / 30 days) QL (240 tabs / 30 days) QL (120 tabs / 30 days) QL (60 tabs / 30 days) QL (120 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) PA; PA for age 65 or older PA; PA for age 65 or older PA; PA for age 65 or older PA; PA for age 65 or older QL (600 mL / 30 days), PA QL (60 caps / 30 days) QL (60 caps / 30 days) QL (90 caps / 30 days) QL (90 caps / 30 days) B/D B/D B/D ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT ADHD amphetamine-dextroamphetamine cap sr $0 (1) 24hr 5 mg amphetamine-dextroamphetamine cap sr $0 (1) 24hr 10 mg QL (90 caps / 30 days) QL (90 caps / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 53 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) amphetamine-dextroamphetamine cap sr $0 (1) 24hr 15 mg amphetamine-dextroamphetamine cap sr $0 (1) 24hr 20 mg amphetamine-dextroamphetamine cap sr $0 (1) 24hr 25 mg amphetamine-dextroamphetamine cap sr $0 (1) 24hr 30 mg amphetamine-dextroamphetamine tab 5 $0 (1) mg amphetamine-dextroamphetamine tab 7.5 $0 (1) mg amphetamine-dextroamphetamine tab 10 $0 (1) mg amphetamine-dextroamphetamine tab $0 (1) 12.5 mg amphetamine-dextroamphetamine tab 15 $0 (1) mg amphetamine-dextroamphetamine tab 20 $0 (1) mg amphetamine-dextroamphetamine tab 30 $0 (1) mg guanfacine hcl tab sr 24hr 1 mg (base $0-$6.60 (2) equiv) guanfacine hcl tab sr 24hr 2 mg (base $0-$6.60 (2) equiv) guanfacine hcl tab sr 24hr 3 mg (base $0-$6.60 (2) equiv) guanfacine hcl tab sr 24hr 4 mg (base $0-$6.60 (2) equiv) methylphenidate hcl soln 5 mg/5ml $0 (1) methylphenidate hcl soln 10 mg/5ml $0 (1) methylphenidate hcl tab 5 mg $0 (1) methylphenidate hcl tab 10 mg $0 (1) methylphenidate hcl tab 20 mg $0 (1) methylphenidate hcl tab cr 10 mg $0 (1) methylphenidate hcl tab cr 20 mg $0 (1) STRATTERA CAP 10MG $0-$6.60 (2) STRATTERA CAP 18MG $0-$6.60 (2) STRATTERA CAP 25MG $0-$6.60 (2) STRATTERA CAP 40MG $0-$6.60 (2) STRATTERA CAP 60MG $0-$6.60 (2) STRATTERA CAP 80MG $0-$6.60 (2) STRATTERA CAP 100MG $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (30 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days) QL (360 tabs / 30 days) QL (240 tabs / 30 days) QL (180 tabs / 30 days) QL (144 tabs / 30 days) QL (120 tabs / 30 days) QL (90 tabs / 30 days) QL (60 tabs / 30 days) QL QL QL QL QL QL QL QL QL QL QL QL QL QL (1800 mL / 30 days) (900 mL / 30 days) (180 tabs / 30 days) (180 tabs / 30 days) (90 tabs / 30 days) (90 tabs / 30 days) (90 tabs / 30 days) (120 caps / 30 days) (120 caps / 30 days) (120 caps / 30 days) (60 caps / 30 days) (30 caps / 30 days) (30 caps / 30 days) (30 caps / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 54 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) HYPNOTICS - DRUGS TO TREAT INSOMNIA ROZEREM TAB 8MG SILENOR TAB 3MG SILENOR TAB 6MG temazepam cap 7.5 mg $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) temazepam cap 15 mg $0 (1) zolpidem tartrate tab 5 mg $0-$6.60 (2) zolpidem tartrate tab 10 mg $0-$6.60 (2) QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (30 caps / 30 days), PA; 90 day limit if >64 yr QL (60 caps / 30 days), PA; 90 day limit if >64 yr QL (30 tabs / 30 days), PA; 90 day limit if >64 yr QL (30 tabs / 30 days), PA; 90 day limit if >64 yr MIGRAINE - DRUGS TO TREAT SEVERE HEADACHES cafergot tab 1-100mg dihydroergotamine mesylate inj 1 mg/ml naratriptan hcl tab 1 mg (base equiv) naratriptan hcl tab 2.5 mg (base equiv) RELPAX TAB 20MG RELPAX TAB 40MG rizatriptan benzoate orally disintegrating tab 5 mg rizatriptan benzoate orally disintegrating tab 10 mg rizatriptan benzoate tab 5 mg rizatriptan benzoate tab 10 mg SUMATRIPTAN NASAL SPRAY 5 MG/ACT $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0 (1) QL QL QL QL QL $0 (1) QL (18 tabs / 30 days) $0 (1) $0 (1) $0 (1) SUMATRIPTAN NASAL SPRAY 20 MG/ACT $0 (1) sumatriptan succinate inj 6 mg/0.5ml SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 4 MG/0.5ML sumatriptan succinate solution auto-injector 6 mg/0.5ml SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 4 MG/0.5ML SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 6 MG/0.5ML sumatriptan succinate solution prefilled syringe 6 mg/0.5ml sumatriptan succinate tab 25 mg sumatriptan succinate tab 50 mg sumatriptan succinate tab 100 mg $0 (1) $0 (1) QL (18 tabs / 30 days) QL (18 tabs / 30 days) QL (24 inhalers / 30 days) QL (12 inhalers / 30 days) QL (6 mL / 30 days) QL (6 mL / 30 days) $0 (1) QL (6 mL / 30 days) $0 (1) QL (6 mL / 30 days) $0 (1) QL (6 mL / 30 days) $0 (1) QL (6 mL / 30 days) $0 (1) $0 (1) $0 (1) QL (9 tabs / 30 days) QL (9 tabs / 30 days) QL (9 tabs / 30 days) (9 tabs / 30 days) (9 tabs / 30 days) (12 tabs / 30 days) (12 tabs / 30 days) (18 tabs / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 55 Drug Name (By Medical Condition) zolmitriptan mg zolmitriptan zolmitriptan zolmitriptan orally disintegrating tab 2.5 WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) orally disintegrating tab 5 mg $0 (1) tab 2.5 mg $0 (1) tab 5 mg $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (12 tabs / 30 days) QL (12 tabs / 30 days) QL (12 tabs / 30 days) QL (12 tabs / 30 days) MISCELLANEOUS lithium carbonate cap 150 mg lithium carbonate cap 300 mg lithium carbonate cap 600 mg lithium carbonate tab 300 mg lithium carbonate tab cr 300 mg lithium carbonate tab cr 450 mg LITHIUM SOL 8MEQ/5ML NUEDEXTA CAP 20-10MG pyridostigmine bromide tab 60 mg riluzole tab 50 mg TETRABENAZINE TAB 12.5 MG $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0-$6.60 (2) TETRABENAZINE TAB 25 MG $0-$6.60 (2) XENAZINE TAB 12.5MG $0-$6.60 (2) XENAZINE TAB 25MG $0-$6.60 (2) PA QL (240 tabs NM, PA QL (120 tabs NM, PA QL (240 tabs NM, LA, PA QL (120 tabs NM, LA, PA / 30 days), / 30 days), / 30 days), / 30 days), MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSIS BETASERON INJ 0.3MG $0-$6.60 (2) COPAXONE INJ 20MG/ML $0-$6.60 (2) COPAXONE INJ 40MG/ML $0-$6.60 (2) GILENYA CAP 0.5MG $0-$6.60 (2) glatiramer acetate soln prefilled syringe 20 $0-$6.60 (2) mg/ml TYSABRI INJ 300/15ML $0-$6.60 (2) QL (14 syringes / 28 days), NM, PA QL (30 syringes / 30 days), NM, PA QL (12 syringes / 28 days), NM, PA QL (28 caps / 28 days), NM, PA QL (30 syringes / 30 days), NM, PA NM, LA, PA MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS baclofen tab 10 mg baclofen tab 20 mg cyclobenzaprine hcl tab 5 mg $0 (1) $0 (1) $0 (1) PA; PA for age 65 or older PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 56 Drug Name (By Medical Condition) cyclobenzaprine hcl tab 10 mg WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) dantrolene sodium cap dantrolene sodium cap dantrolene sodium cap tizanidine hcl tab 2 mg tizanidine hcl tab 4 mg $0 $0 $0 $0 $0 25 mg 50 mg 100 mg (base equivalent) (base equivalent) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE PA; PA for age 65 or older (1) (1) (1) (1) (1) NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS NUVIGIL TAB 50MG $0-$6.60 (2) NUVIGIL TAB 150MG $0-$6.60 (2) NUVIGIL TAB 200MG $0-$6.60 (2) NUVIGIL TAB 250MG $0-$6.60 (2) XYREM SOL 500MG/ML $0-$6.60 (2) QL (150 tabs / 30 days), PA QL (60 tabs / 30 days), PA QL (30 tabs / 30 days), PA QL (30 tabs / 30 days), PA QL (540 mL / 30 days), LA, PA PSYCHOTHERAPEUTIC-MISC acamprosate calcium tab delayed release $0 (1) 333 mg buprenorphine hcl sl tab 2 mg (base equiv)$0 (1) buprenorphine hcl sl tab 8 mg (base equiv)$0 (1) buprenorphine hcl-naloxone hcl sl tab 2-0.5$0 (1) mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 $0 (1) mg (base equiv) buproban tab 150mg $0 (1) CHANTIX PAK 0.5& 1MG $0-$6.60 CHANTIX PAK 1MG $0-$6.60 CHANTIX TAB 0.5MG $0-$6.60 CHANTIX TAB 1MG $0-$6.60 disulfiram tab 250 mg $0 (1) disulfiram tab 500 mg $0 (1) gnp nicotine gum 2mg mint $0 (3) gnp nicotine gum 2mg orig $0 (3) gnp nicotine gum 4mg mint $0 (3) gnp nicotine gum 4mg orig $0 (3) gnp nicotine loz 2mg mint $0 (3) gnp nicotine loz 4mg mint $0 (3) naloxone hcl inj 0.4 mg/ml $0 (1) naloxone hcl inj 1 mg/ml $0 (1) naltrexone hcl tab 50 mg $0 (1) PA PA QL (120 tabs / 30 days), PA QL (120 tabs / 30 days), PA (2) (2) (2) (2) PA PA PA PA NM; NM; NM; NM; NM; NM; * * * * * * PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 57 Drug Name (By Medical Condition) nicorelief gum 2mg mint nicorelief gum 2mg orig nicorelief gum 4mg mint nicorelief gum 4mg orig nicotine polacrilex gum 2 mg nicotine polacrilex gum 4 mg nicotine td patch 24hr 7 mg/24hr NICOTINE TD PATCH 24HR 7 MG/24HR nicotine td patch 24hr 14 mg/24hr NICOTINE TD PATCH 24HR 14 MG/24HR nicotine td patch 24hr 21 mg/24hr NICOTINE TD PATCH 24HR 21 MG/24HR NICOTROL INH NICOTROL NS SPR 10MG/ML sm nicotine dis 7mg/24hr sm nicotine dis 14mg/24h sm nicotine dis 21mg sm nicotine gum 2mg mint sm nicotine gum 4mg sm nicotine gum 4mg mint sm nicotine loz 4mg mint SUBOXONE MIS 2-0.5MG WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0-$6.60 (2) $0-$6.60 (2) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0-$6.60 (2) SUBOXONE MIS 4-1MG $0-$6.60 (2) SUBOXONE MIS 8-2MG $0-$6.60 (2) SUBOXONE MIS 12-3MG $0-$6.60 (2) thrive gum 2mg mint thrive gum 4mg mint $0 (3) $0 (3) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; * * * * * * * * * * * * NM; * NM; * NM; * NM; * NM; * NM; * NM; * QL (4 boxes PA QL (4 boxes PA QL (4 boxes PA QL (2 boxes PA NM; * NM; * / 30 days), / 30 days), / 30 days), / 30 days), ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS - DRUGS TO REGULATE MALE HORMONES ANDRODERM DIS 2MG/24HR $0-$6.60 (2) ANDRODERM DIS 4MG/24HR $0-$6.60 (2) oxandrolone tab 2.5 mg oxandrolone tab 10 mg TESTIM GEL 1%(50MG) $0 (1) $0 (1) $0-$6.60 (2) QL (30 patches / 30 days), PA QL (30 patches / 30 days), PA PA PA QL (300 grams / 30 days), PA testosterone cypionate im inj in oil 100 $0 (1) mg/ml PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 58 Drug Name (By Medical Condition) testosterone cypionate im inj in oil 200 mg/ml testosterone enanthate im inj in oil 200 mg/ml WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0 (1) ANTIDIABETICS, INJECTABLE - DRUGS TO TREAT DIABETES ALCOHOL SWABS GAUZE PADS 2" X 2" HUMULIN R INJ U-500 INSULIN PEN NEEDLE INSULIN SAFETY NEEDLES INSULIN SYRINGE LANTUS INJ 100/ML LANTUS INJ SOLOSTAR LEVEMIR INJ LEVEMIR INJ FLEXTOUC NOVOLIN INJ 70/30 NOVOLIN N INJ U-100 NOVOLIN R INJ U-100 NOVOLOG INJ 100/ML NOVOLOG INJ FLEXPEN NOVOLOG INJ PENFILL NOVOLOG MIX INJ 70/30 NOVOLOG MIX INJ FLEXPEN SYMLINPEN 60 INJ 1000MCG SYMLNPEN 120 INJ 1000MCG TOUJEO SOLO INJ 300IU/ML TRULICITY INJ 0.75/0.5 TRULICITY INJ 1.5/0.5 VICTOZA INJ 18MG/3ML $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) B/D RELION not covered RELION not covered RELION not covered QL (8 pens / 30 days), PA QL (4 pens / 30 days), PA QL (4 pens / 28 days) QL (4 pens / 28 days) QL (3 pens / 30 days) ANTIDIABETICS, ORAL - DRUGS TO TREAT DIABETES acarbose tab 25 mg acarbose tab 50 mg acarbose tab 100 mg FARXIGA TAB 5MG FARXIGA TAB 10MG glimepiride tab 1 mg glimepiride tab 2 mg glimepiride tab 4 mg glipizide tab 5 mg glipizide tab 10 mg glipizide tab sr 24hr 2.5 mg glipizide tab sr 24hr 5 mg glipizide tab sr 24hr 10 mg $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) QL QL QL QL QL QL QL QL QL QL (60 tabs / 30 days) (30 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 59 Drug Name (By Medical Condition) glipizide-metformin hcl tab 2.5-250 mg glipizide-metformin hcl tab 2.5-500 mg glipizide-metformin hcl tab 5-500 mg INVOKAMET TAB 50-500MG INVOKAMET TAB 50-1000 INVOKAMET TAB 150-500 INVOKAMET TAB 150-1000 INVOKANA TAB 100MG INVOKANA TAB 300MG JANUMET TAB 50-500MG JANUMET TAB 50-1000 JANUMET XR TAB 50-500MG JANUMET XR TAB 50-1000 JANUMET XR TAB 100-1000 JANUVIA TAB 25MG JANUVIA TAB 50MG JANUVIA TAB 100MG JENTADUETO TAB 2.5-500 JENTADUETO TAB 2.5-850 JENTADUETO TAB 2.5-1000 metformin hcl tab 500 mg metformin hcl tab 850 mg metformin hcl tab 1000 mg metformin hcl tab sr 24hr 500 mg metformin hcl tab sr 24hr 750 mg nateglinide tab 60 mg nateglinide tab 120 mg pioglitazone hcl tab 15 mg (base equiv) pioglitazone hcl tab 30 mg (base equiv) pioglitazone hcl tab 45 mg (base equiv) repaglinide tab 0.5 mg repaglinide tab 1 mg repaglinide tab 2 mg RIOMET SOL TRADJENTA TAB 5MG XIGDUO XR TAB 5-500MG XIGDUO XR TAB 5-1000MG XIGDUO XR TAB 10-500MG XIGDUO XR TAB 10-1000 WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) BISPHOSPHONATES - DRUGS TO TREAT alendronate sodium tab 5 mg alendronate sodium tab 10 mg alendronate sodium tab 35 mg $0 (1) $0 (1) $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL (240 tabs / 30 days) (120 tabs / 30 days) (120 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (90 tabs / 30 days) (30 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (150 tabs / 30 days) (90 tabs / 30 days) (75 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (90 tabs / 30 days) (90 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (120 tabs / 30 days) (120 tabs / 30 days) (240 tabs / 30 days) (946 mL / 30 days) (30 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) BONE LOSS QL (4 tabs / 28 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 60 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0 (1) $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE $0 (1) $0 (1) $0 (1) $0-$6.60 (2) B/D B/D B/D B/D, NM $0-$6.60 (2) B/D, NM SENSIPAR TAB 30MG $0-$6.60 (2) SENSIPAR TAB 60MG $0-$6.60 (2) SENSIPAR TAB 90MG $0-$6.60 (2) QL (120 tabs / 30 days), NM QL (60 tabs / 30 days), NM QL (120 tabs / 30 days), NM alendronate sodium tab 40 mg alendronate sodium tab 70 mg ibandronate sodium tab 150 mg (base equivalent) pamidronate disodium iv soln 3 mg/ml pamidronate disodium iv soln 9 mg/ml pamidronate inj 6mg/ml zoledronic acid inj conc for iv infusion 4 mg/5ml ZOMETA INJ 4MG/100 QL (4 tabs / 28 days) B/D, QL (1 tab / 30 days) CALCIUM RECEPTOR AGONISTS CHELATING AGENTS CHEMET CAP 100MG $0-$6.60 DEPEN TITRA TAB 250MG $0-$6.60 EXJADE TAB 125MG $0-$6.60 EXJADE TAB 250MG $0-$6.60 EXJADE TAB 500MG $0-$6.60 kionex pow $0 (1) kionex sus 15gm/60 $0 (1) sodium polystyrene sulfonate oral susp 15 $0 (1) gm/60ml sps sus 15gm/60 $0 (1) SYPRINE CAP 250MG $0-$6.60 (2) (2) (2) (2) (2) NM, LA, PA NM, LA, PA NM, LA, PA (2) CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL altavera tab apri tab aranelle tab aubra tab 0.1-0.02 aviane tab balziva tab briellyn tab camila tab 0.35mg cryselle-28 tab 28 tabs cyclafem tab 1/35 cyclafem tab 7/7/7 deblitane tab 0.35mg delyla tab 0.1-0.02 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 61 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) desogestrel & ethinyl estradiol tab 0.15 $0 (1) mg-30 mcg drospirenone-ethinyl estradiol tab 3-0.02 $0 (1) mg DROSPIRENONE-ETHINYL ESTRADIOL TAB $0 (1) 3-0.02 MG drospirenone-ethinyl estradiol tab 3-0.03 $0 (1) mg DROSPIRENONE-ETHINYL ESTRADIOL TAB $0 (1) 3-0.03 MG ELLA TAB 30MG $0-$6.60 (2) emoquette tab $0 (1) enpresse-28 tab $0 (1) errin tab 0.35mg $0 (1) falmina tab $0 (1) gildagia tab 0.4-35 $0 (1) gildess tab 1.5/30 $0 (1) heather tab 0.35mg $0 (1) introvale tab $0 (1) JOLIVETTE TAB 0.35MG $0 (1) junel 1.5/30 tab $0 (1) junel 1/20 tab $0 (1) junel fe tab 1.5/30 $0 (1) junel fe tab 1/20 $0 (1) kariva tab 28 day $0 (1) kimidess tab $0 (1) larin fe tab 1.5/30 $0 (1) larin fe tab 1/20 $0 (1) larin tab 1.5/30 $0 (1) larin tab 1/20 $0 (1) lessina tab $0 (1) levonest tab $0 (1) levonorgestrel & ethinyl estradiol (91-day) $0 (1) tab 0.15-0.03 mg LEVONORGESTREL & ETHINYL ESTRADIOL $0 (1) (91-DAY) TAB 0.15-0.03 MG levonorgestrel & ethinyl estradiol tab 0.1 $0 (1) mg-20 mcg levonorgestrel tab 0.75 mg $0 (1) levonorgestrel tab 1.5 mg $0 (1) levora-28 tab 0.15/30 $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 62 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) loryna tab 3-0.02mg $0 (1) low-ogestrel tab $0 (1) lutera tab $0 (1) lyza tab 0.35mg $0 (1) marlissa tab 0.15/30 $0 (1) medroxyprogesterone acetate im susp 150 $0 (1) mg/ml microgestin tab 1.5/30 $0 (1) microgestin tab 1/20 $0 (1) microgestin tab fe1.5/30 $0 (1) microgestin tab fe 1/20 $0 (1) MONONESSA TAB $0 (1) my way tab 1.5mg $0 (1) myzilra tab $0 (1) necon tab 0.5/35 $0 (1) necon tab 1/35 $0 (1) NECON TAB 1/50-28 $0 (1) NECON TAB 7/7/7 $0 (1) necon tab 10/11-28 $0-$6.60 (2) next choice tab 1.5mg $0 (1) nikki tab 3-0.02mg $0 (1) norelgestromin-ethinyl estradiol td ptwk $0 (1) 150-35 mcg/24hr norethindrone ace & ethinyl estradiol-fe tab$0 (1) 1 mg-20 mcg norethindrone tab 0.35 mg $0 (1) NORETHINDRONE TAB 0.35 MG $0 (1) NORETHINDRONE-ETH ESTRADIOL TAB $0 (1) 0.5-35/1-35/0.5-35 MG-MCG norgestimate-eth estrad tab $0 (1) 0.18-35/0.215-35/0.25-35 mg-mcg norlyroc tab 0.35mg $0 (1) nortrel tab 0.5/35 $0 (1) nortrel tab 1/35 $0 (1) nortrel tab 7/7/7 $0 (1) NUVARING MIS $0-$6.60 (2) orsythia tab $0 (1) philith tab 0.4-35 $0 (1) pimtrea tab $0 (1) pirmella tab 1/35 $0 (1) portia-28 tab $0 (1) previfem tab $0 (1) quasense tab $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 63 Drug Name (By Medical Condition) reclipsen tab sharobel tab 0.35mg SOLIA TAB sprintec 28 tab 28 day syeda tab 3-0.03mg tri-legest tab fe tri-previfem tab tri-sprintec tab TRINESSA TAB trivora-28 tab velivet pak viorele tab vyfemla tab 0.4-35 zarah tab 3-0.03mg zenchent tab WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) ENDOMETRIOSIS danazol cap 50 mg danazol cap 100 mg danazol cap 200 mg SYNAREL SOL 2MG/ML $0 (1) $0 (1) $0 (1) $0-$6.60 (2) ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES ADAGEN INJ 250/ML $0-$6.60 (2) NM, LA, PA ALDURAZYME INJ 2.9MG/5M $0-$6.60 (2) NM, LA, PA CARBAGLU TAB 200MG $0-$6.60 (2) NM, LA, PA CERDELGA CAP 84MG $0-$6.60 (2) NM, PA CEREZYME INJ 200UNIT $0-$6.60 (2) NM, PA CEREZYME INJ 400UNIT $0-$6.60 (2) NM, PA CYSTADANE POW $0-$6.60 (2) NM CYSTAGON CAP 50MG $0-$6.60 (2) NM, PA CYSTAGON CAP 150MG $0-$6.60 (2) NM, PA FABRAZYME INJ 5MG $0-$6.60 (2) NM, PA FABRAZYME INJ 35MG $0-$6.60 (2) NM, PA KUVAN POW 100MG $0-$6.60 (2) NM, PA KUVAN POW 500MG $0-$6.60 (2) NM, PA KUVAN TAB 100MG $0-$6.60 (2) NM, PA levocarnitine inj 200 mg/ml $0 (1) B/D levocarnitine oral soln 1 gm/10ml (10%) $0 (1) B/D levocarnitine tab 330 mg $0 (1) B/D LUMIZYME INJ 50MG $0-$6.60 (2) NM, PA MYOZYME INJ 50MG $0-$6.60 (2) NM, PA NAGLAZYME INJ 1MG/ML $0-$6.60 (2) NM, LA, PA ORFADIN CAP 2MG $0-$6.60 (2) NM, PA ORFADIN CAP 5MG $0-$6.60 (2) NM, PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 64 Drug Name (By Medical Condition) ORFADIN CAP 10MG sodium phenylbutyrate oral powder 3 gm/teaspoonful ZAVESCA CAP 100MG WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE $0-$6.60 (2) NM, LA, PA NM, PA NM ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES COMBIPATCH DIS .05/.14 $0-$6.60 (2) COMBIPATCH DIS .05/.25 $0-$6.60 (2) estradiol tab 0.5 mg $0-$6.60 (2) estradiol tab 1 mg $0-$6.60 (2) estradiol tab 2 mg $0-$6.60 (2) estradiol td patch weekly 0.1 mg/24hr $0-$6.60 (2) estradiol td patch weekly 0.05 mg/24hr $0-$6.60 (2) estradiol td patch weekly 0.06 mg/24hr $0-$6.60 (2) estradiol td patch weekly 0.025 mg/24hr $0-$6.60 (2) estradiol td patch weekly 0.075 mg/24hr $0-$6.60 (2) estradiol td patch weekly 0.0375 mg/24hr $0-$6.60 (2) (37.5 mcg/24hr) ESTRADIOL VALERATE IM IN OIL 10 MG/ML$0 (1) estradiol valerate im in oil 20 mg/ml $0 (1) ESTRADIOL VALERATE IM IN OIL 40 MG/ML$0 (1) PREMARIN VAG CRE 0.625MG $0-$6.60 (2) VAGIFEM TAB 10MCG $0-$6.60 (2) PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE a-hydrocort inj 100mg cortisone acetate tab 25 mg dexamethason con 1mg/ml dexamethasone elixir 0.5 mg/5ml dexamethasone sod phosphate preservative free inj 10 mg/ml dexamethasone sodium phosphate inj 10 mg/ml dexamethasone sodium phosphate inj 20 mg/5ml $0 $0 $0 $0 $0 (1) (1) (1) (1) (1) $0 (1) $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 65 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) dexamethasone sodium phosphate inj 100 $0 (1) mg/10ml dexamethasone sodium phosphate inj 120 $0 (1) mg/30ml dexamethasone soln 0.5 mg/5ml $0 (1) dexamethasone tab 0.5 mg $0 (1) dexamethasone tab 0.75 mg $0 (1) dexamethasone tab 1 mg $0 (1) dexamethasone tab 1.5 mg $0 (1) dexamethasone tab 2 mg $0 (1) dexamethasone tab 4 mg $0 (1) dexamethasone tab 6 mg $0 (1) fludrocortisone acetate tab 0.1 mg $0 (1) hydrocortisone tab 5 mg $0 (1) hydrocortisone tab 10 mg $0 (1) hydrocortisone tab 20 mg $0 (1) methylprednisolone acetate inj susp 40 $0 (1) B/D mg/ml methylprednisolone acetate inj susp 80 $0 (1) B/D mg/ml methylprednisolone sodium succinate for $0 (1) B/D inj 40 mg methylprednisolone sodium succinate for $0 (1) B/D inj 125 mg methylprednisolone sodium succinate for $0 (1) B/D inj 1000 mg methylprednisolone tab 4 mg $0 (1) B/D methylprednisolone tab 4 mg dose pack $0 (1) B/D methylprednisolone tab 8 mg $0 (1) B/D methylprednisolone tab 16 mg $0 (1) B/D methylprednisolone tab 32 mg $0 (1) B/D prednisolone sod phosph oral soln 6.7 $0 (1) B/D mg/5ml (5 mg/5ml base) prednisolone sod phosphate oral soln 15 $0 (1) B/D mg/5ml (base equiv) prednisolone sodium phosphate oral soln $0 (1) B/D 25 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp $0 (1) B/D solution equivalent) prednisone con 5mg/ml $0-$6.60 (2) B/D prednisone oral soln 5 mg/5ml $0 (1) B/D prednisone tab 1 mg $0 (1) B/D prednisone tab 2.5 mg $0 (1) B/D prednisone tab 5 mg $0 (1) B/D PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 66 Drug Name (By Medical Condition) prednisone tab 5 mg dose pack prednisone tab 10 mg prednisone tab 10 mg dose pack prednisone tab 20 mg prednisone tab 50 mg SOLU-CORTEF INJ 250MG WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE B/D B/D B/D B/D B/D GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD SUGAR GLUCAGEN INJ HYPOKIT GLUCAGON KIT 1MG GLUCOSE CHW 4GM glutose 15 gel 40% HM GLUCOSE CHW ORANGE insta-glucos gel 77.4% PROGLYCEM SUS 50MG/ML SM GLUCOSE CHW ORANGE SM GLUCOSE CHW RASPBERY SM GLUCOSE CHW SOUR APP $0-$6.60 (2) $0-$6.60 (2) $0 (3) $0 (3) $0 (3) $0 (3) $0-$6.60 (2) $0 (3) $0 (3) $0 (3) NM; NM; NM; NM; * * * * NM; * NM; * NM; * HUMAN GROWTH HORMONES - DRUGS TO REGULATE PITUITARY HORMONES NORDITROPIN INJ 5/1.5ML NORDITROPIN INJ 10/1.5ML NORDITROPIN INJ 15/1.5ML NORDITROPIN INJ 30/3ML TEV-TROPIN INJ 5MG $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) (2) NM, NM, NM, NM, NM, PA PA PA PA PA (2) (2) NM, LA, PA MISCELLANEOUS cabergoline tab 0.5 mg $0 (1) calcitonin (salmon) nasal soln 200 unit/act $0 (1) FORTICAL SPR 200/ACT $0-$6.60 INCRELEX INJ 40MG/4ML $0-$6.60 methylergonovine maleate tab 0.2 mg $0 (1) MIACALCIN INJ 200/ML $0-$6.60 octreotide acetate inj 50 mcg/ml (0.05 $0 (1) mg/ml) octreotide acetate inj 100 mcg/ml (0.1 $0 (1) mg/ml) octreotide acetate inj 200 mcg/ml (0.2 $0 (1) mg/ml) octreotide acetate inj 500 mcg/ml (0.5 $0-$6.60 mg/ml) octreotide acetate inj 1000 mcg/ml (1 $0-$6.60 mg/ml) (2) B/D NM, PA NM, PA NM, PA (2) NM, PA (2) NM, PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 67 Drug Name (By Medical Condition) PROLIA SOL 60MG/ML WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) raloxifene hcl tab 60 mg SANDOSTATIN KIT LAR 10MG SANDOSTATIN KIT LAR 20MG SANDOSTATIN KIT LAR 30MG SOMATULINE INJ 60/0.2ML SOMATULINE INJ 90/0.3ML SOMATULINE INJ 120/.5ML SOMAVERT INJ 10MG SOMAVERT INJ 15MG SOMAVERT INJ 20MG SOMAVERT INJ 25MG SOMAVERT INJ 30MG XGEVA INJ $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (1 syringe / 180 days), NM NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, PA PA PA PA PA PA LA, LA, LA, LA, LA, PA PA PA PA PA PA PARATHYROID HORMONES - DRUGS TO REGULATE PARATHYROID LEVELS FORTEO SOL 600/2.4 $0-$6.60 (2) QL (1 pen / 28 days), NM, PA PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS calcium acetate (phosphate binder) cap 667 mg (169 mg ca) FOSRENOL CHW 500MG FOSRENOL CHW 750MG FOSRENOL CHW 1000MG PHOSLYRA SOL RENVELA PAK 0.8GM RENVELA PAK 2.4GM RENVELA TAB 800MG $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) (2) (2) (2) PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES medroxyprogesterone acetate tab 2.5 mg medroxyprogesterone acetate tab 5 mg medroxyprogesterone acetate tab 10 mg norethindrone acetate tab 5 mg $0 $0 $0 $0 (1) (1) (1) (1) THYROID AGENTS - DRUGS TO REGULATE levothyroxine levothyroxine levothyroxine levothyroxine levothyroxine levothyroxine sodium sodium sodium sodium sodium sodium tab tab tab tab tab tab 25 mcg 50 mcg 75 mcg 88 mcg 100 mcg 112 mcg $0 $0 $0 $0 $0 $0 THYROID LEVELS (1) (1) (1) (1) (1) (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 68 Drug Name (By Medical Condition) levothyroxine sodium tab 125 mcg levothyroxine sodium tab 137 mcg levothyroxine sodium tab 150 mcg levothyroxine sodium tab 175 mcg levothyroxine sodium tab 200 mcg levothyroxine sodium tab 300 mcg LEVOXYL TAB 25MCG LEVOXYL TAB 50MCG LEVOXYL TAB 75MCG LEVOXYL TAB 88MCG LEVOXYL TAB 100MCG LEVOXYL TAB 112MCG LEVOXYL TAB 125MCG LEVOXYL TAB 137MCG LEVOXYL TAB 150MCG LEVOXYL TAB 175MCG LEVOXYL TAB 200MCG liothyronine sodium tab 5 mcg liothyronine sodium tab 25 mcg liothyronine sodium tab 50 mcg methimazole tab 5 mg methimazole tab 10 mg propylthiouracil tab 50 mg SYNTHROID TAB 25MCG SYNTHROID TAB 50MCG SYNTHROID TAB 75MCG SYNTHROID TAB 88MCG SYNTHROID TAB 100MCG SYNTHROID TAB 112MCG SYNTHROID TAB 125MCG SYNTHROID TAB 137MCG SYNTHROID TAB 150MCG SYNTHROID TAB 175MCG SYNTHROID TAB 200MCG SYNTHROID TAB 300MCG UNITHROID TAB 25MCG UNITHROID TAB 50MCG UNITHROID TAB 75MCG UNITHROID TAB 88MCG UNITHROID TAB 100MCG UNITHROID TAB 112MCG UNITHROID TAB 125MCG WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 69 Drug Name (By Medical Condition) UNITHROID UNITHROID UNITHROID UNITHROID TAB TAB TAB TAB 150MCG 175MCG 200MCG 300MCG WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES desmopressin acetate inj 4 mcg/ml DESMOPRESSIN ACETATE NASAL SOLN 0.01% (REFRIGERATED) desmopressin acetate nasal spray soln 0.01% desmopressin acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab 0.1 mg desmopressin acetate tab 0.2 mg $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ANTACIDS acid gone sus almacone dbl sus strength almacone sus ALUM HYDROX SUS 320/5ML antacid chw 500mg antacid chw 750mg antacid chw 1000mg antacid fast sus acting antacid plus sus gas rel antacid sus antacid sus max st antacid sus reg st cal-gest chw 500mg calc antacid chw 500mg calc antacid chw 750mg GAVISCON CHW gnp antacid chw 1000mg gnp antacid sus anti-gas gnp antacid sus cherry gnp masanti sus max st gnp masanti sus reg st hm antacid sus anti-gas maalox advan sus max st mi-acid chw mi-acid sus mi-acid sus max st $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; * * * * * * * * * * * * * * * * * * * * * * * * * * PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 70 Drug Name (By Medical Condition) mintox plus chw mintox sus mintox sus max st rulox sus sm antacid sus anti-gas sm antacid/ sus antigas sodium bicarbonate tab 325 mg sodium bicarbonate tab 650 mg WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE NM; NM; NM; NM; NM; NM; NM; NM; * * * * * * * * $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; * * * * * * * * * * * * * * * * ANTI-DIARRHEAL anti-diarrhe tab 2mg bismatrol chw 262mg bismatrol sus 262/15ml bismatrol sus 525/15ml gnp k-pec sus 262/15ml kao-tin sus 262/15ml loperamide hcl liq 1 mg/5ml (0.2 mg/ml) loperamide hcl liq 1 mg/7.5ml loperamide sus 1mg/7.5 peptic relf chw 262mg pink bismuth chw 262mg sm anti-diar tab 2mg sm stomach sus 262/15ml stomach relf chw 262mg stomach relf sus 262/15ml stomach relf sus 525/15ml (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING compro sup 25mg dimenhydrinate tab 50 mg driminate tab 50mg dronabinol cap 2.5 mg $0 $0 $0 $0 (1) (3) (3) (1) dronabinol cap 5 mg $0 (1) dronabinol cap 10 mg $0-$6.60 (2) EMEND CAP 40MG EMEND CAP 80MG EMEND CAP 125MG EMEND PAK 80 & 125 granisetron hcl inj 0.1 mg/ml granisetron hcl inj 1 mg/ml granisetron hcl inj 4 mg/4ml (1 mg/ml) granisetron hcl tab 1 mg $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) NM; * NM; * B/D, QL (60 caps / 30 days) B/D, QL (60 caps / 30 days) B/D, QL (60 caps / 30 days) B/D B/D B/D B/D B/D PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 71 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) meclizine hcl tab 12.5 mg meclizine hcl tab 25 mg metoclopramide hcl inj 5 mg/ml metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) metoclopramide hcl tab 5 mg $0 (1) metoclopramide hcl tab 10 mg $0 (1) motion sick tab 25mg $0 (3) ondansetron hcl inj 4 mg/2ml (2 mg/ml) $0 (1) ondansetron hcl inj 40 mg/20ml (2 mg/ml)$0 (1) ondansetron hcl oral soln 4 mg/5ml $0 (1) ondansetron hcl tab 4 mg $0 (1) ondansetron hcl tab 8 mg $0 (1) ondansetron hcl tab 24 mg $0 (1) ondansetron orally disintegrating tab 4 mg $0 (1) ondansetron orally disintegrating tab 8 mg $0 (1) prochlorperazine edisylate inj 5 mg/ml $0 (1) prochlorperazine maleate tab 5 mg (base $0 (1) equivalent) prochlorperazine maleate tab 10 mg (base $0 (1) equivalent) prochlorperazine suppos 25 mg $0 (1) promethazine hcl inj 25 mg/ml $0-$6.60 (2) promethazine hcl inj 50 mg/ml $0-$6.60 (2) TRANSDERM-SC DIS 1MG $0-$6.60 (2) travel sick chw 25mg $0 (3) NM; * B/D B/D B/D B/D B/D B/D PA; PA for age 65 or older PA; PA for age 65 or older QL (10 patches / 30 days), PA; PA for age 65 or older NM; * ANTISPASMODICS - DRUGS FOR STOMACH SPASMS CUVPOSA SOL 1MG/5ML dicyclomine hcl cap 10 mg dicyclomine hcl oral soln 10 mg/5ml dicyclomine hcl tab 20 mg glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) glycopyrrolate tab 1 mg glycopyrrolate tab 2 mg $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACID acid reducer tab 10mg acid reducer tab 75mg famotidine for susp 40 mg/5ml $0 (3) $0 (3) $0 (1) NM; * NM; * PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 72 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) famotidine in nacl 0.9% iv soln 20 mg/50ml$0 (1) famotidine inj 20 mg/2ml $0 (1) famotidine inj 40 mg/4ml $0 (1) famotidine inj 200 mg/20ml $0 (1) famotidine tab 10 mg $0 (3) famotidine tab 20 mg $0 (1) famotidine tab 40 mg $0 (1) heartburn tab relief $0 (3) ranitidine hcl inj 50 mg/2ml (25 mg/ml) $0 (1) ranitidine hcl inj 150 mg/6ml (25 mg/ml) $0 (1) ranitidine hcl syrup 15 mg/ml (75 mg/5ml)$0 (1) ranitidine hcl tab 75 mg $0 (3) ranitidine hcl tab 150 mg $0 (1) ranitidine hcl tab 300 mg $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE NM; * NM; * NM; * INFLAMMATORY BOWEL DISEASE APRISO CAP 0.375GM $0-$6.60 ASACOL HD TAB 800MG $0-$6.60 balsalazide disodium cap 750 mg $0 (1) budesonide cap sr 24hr 3 mg $0-$6.60 CANASA SUP 1000MG $0-$6.60 DELZICOL CAP 400MG $0-$6.60 DIPENTUM CAP 250MG $0-$6.60 hydrocortisone enema 100 mg/60ml $0 (1) HYDROCORTISONE ENEMA 100 MG/60ML $0 (1) LIALDA TAB 1.2GM $0-$6.60 mesalamine enema 4 gm $0 (1) mesalamine rectal enema 4 gm & cleanser $0 (1) wipe kit PENTASA CAP 250MG CR $0-$6.60 PENTASA CAP 500MG CR $0-$6.60 sulfasalazine tab 500 mg $0 (1) sulfazine ec tab 500mg $0 (1) UCERIS TAB 9MG $0-$6.60 (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) LAXATIVES bisac-evac sup 10mg $0 (3) NM; * bisacodyl suppos 10 mg $0 (3) NM; * bisacodyl tab 5mg ec $0 (3) NM; * bisacodyl tab & peg 3350-kcl-sod $0 (1) bicarb-nacl for soln kit biscolax sup 10mg $0 (3) NM; * calcium polycarbophil tab 625 mg $0 (3) NM; * CITRUCEL POW ORANGE $0 (3) NM; * CITRUCEL POW SF ORANG $0 (3) NM; * PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 73 Drug Name (By Medical Condition) constulose sol 10gm/15 cvs fiber la tab 625mg diocto liq 50mg/5ml doc-q-lax tab 8.6-50mg docqlace cap 100mg docu liq 50mg/5ml docusate sod cap 100mg docusate sodium cap 100 mg docusil cap 100mg dok cap 100mg dok cap 250mg dok tab 100mg ducodyl tab 5mg ec enulose sol 10gm/15 EX-LAX TAB 15MG fiber laxatv tab 625mg fiber laxtiv cap 0.52gm fiber therap tab 500mg fiber-caps tab 625mg fiber-lax tab 625mg gavilyte-c sol gavilyte-g sol gavilyte-n sol flav pk generlac sol 10gm/15 glycerin sup 2.1gm glycerin sup 2gm gnp glycerin sup 2.1gm gnp milk mag sus GOLYTELY SOL hm fiber pow 48.57% kao-tin cap 240mg konsyl cap 520mg konsyl pow 30.9% KONSYL-D POW 52.3% lactulose (encephalopathy) solution 10 gm/15ml lactulose solution 10 gm/15ml lax/stl soft tab 8.6-50mg laxative sup 10mg metamucil pow 28.3%org metamucil pow 58.6% metamucil pow 58.6%org milk of magn sus WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (1) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (1) $0 (1) $0 (1) $0 (1) $0 (3) $0 (3) $0 (3) $0 (3) $0-$6.60 (2) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (1) $0 $0 $0 $0 $0 $0 $0 (1) (3) (3) (3) (3) (3) (3) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; * * * * * * * * * * * * NM; NM; NM; NM; NM; NM; * * * * * * NM; NM; NM; NM; * * * * NM; NM; NM; NM; NM; * * * * * NM; NM; NM; NM; NM; NM; * * * * * * PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 74 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) milk of magn sus 400/5ml $0 (3) NM; * milk of magn sus 1200/15 $0 (3) NM; * milk of magn sus frsh mnt $0 (3) NM; * milk of magn sus mint $0 (3) NM; * MOVIPREP SOL $0-$6.60 (2) nat fiber pow 48.57% $0 (3) NM; * nat fiber pow therapy $0 (3) NM; * naturl fiber pow 28.3% $0 (3) NM; * naturl fiber pow therapy $0 (3) NM; * NULYTELY SOL FLAV PKS $0-$6.60 (2) NUTRISOURCE POW FIBER $0 (3) NM; * oral saline sol laxative $0 (3) NM; * peg 3350-kcl-na bicarb-nacl-na sulfate for $0 (1) soln 236 gm PEG 3350-KCL-NA BICARB-NACL-NA $0 (1) SULFATE FOR SOLN 240 GM peg 3350-kcl-sod bicarb-nacl for soln 420 $0 (1) gm peri-colace tab 8.6-50mg $0 (3) NM; * polyethylene glycol 3350 oral packet $0 (1) polyethylene glycol 3350 oral powder $0 (1) reguloid cap 0.52gm $0 (3) NM; * reguloid pow 28.3% $0 (3) NM; * reguloid pow 48.57% $0 (3) NM; * reguloid pow 58.6% $0 (3) NM; * RELISTOR INJ 8/0.4ML $0-$6.60 (2) PA RELISTOR INJ 12/0.6ML $0-$6.60 (2) PA RELISTOR KIT 12/0.6ML $0-$6.60 (2) PA sb milk magn sus $0 (3) NM; * senexon tab 8.6mg $0 (3) NM; * senna lax tab 8.6mg $0 (3) NM; * senna plus tab 8.6-50mg $0 (3) NM; * SENNA TAB 8.6MG $0 (3) NM; * senna-lax tab 8.6mg $0 (3) NM; * sennalax-s tab 8.6-50mg $0 (3) NM; * sennosides syrup 8.8 mg/5ml $0 (3) NM; * sennosides tab 8.6 mg $0 (3) NM; * sennosides tab 15 mg $0 (3) NM; * sennosides-docusate sodium tab 8.6-50 mg$0 (3) NM; * silace liq 10mg/ml $0 (3) NM; * silace syp 60/15ml $0 (3) NM; * sm fiber lax cap 0.52gm $0 (3) NM; * sm fiber lax tab 500mg $0 (3) NM; * sm fiber pow 28.3% $0 (3) NM; * PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not 75 available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid Drug Name (By Medical Condition) sm fiber pow 48.57% sm fiber pow 58.6% sm laxative tab 5mg ec sm milk magn sus mint sm senna lax tab 8.6mg soluble fib pow therapy stim laxat tab 5mg ec stool softnr cap 100mg stool softnr cap 240mg stool softnr cap 250mg stool softnr tab 8.6-50mg SUPREP BOWEL SOL PREP total fiber pow trilyte sol WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0-$6.60 (2) $0 (3) $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) (2) (2) (2) (2) (2) PA PA QL (60 caps / 30 days) QL (60 caps / 30 days) (2) (2) QL (60 caps / 30 days) QL (30 caps / 30 days) (2) (2) PA PA (2) (2) (2) QL (60 tabs / 30 days) QL (30 tabs / 30 days) (2) PA NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; * * * * * * * * * * * NM; * MISCELLANEOUS alosetron hcl tab 0.5 mg (base equiv) alosetron hcl tab 1 mg (base equiv) AMITIZA CAP 8MCG AMITIZA CAP 24MCG cromolyn sodium oral conc 100 mg/5ml diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml diphenoxylate w/ atropine tab 2.5-0.025 mg LINZESS CAP 145MCG LINZESS CAP 290MCG loperamide hcl cap 2 mg LOTRONEX TAB 0.5MG LOTRONEX TAB 1MG misoprostol tab 100 mcg misoprostol tab 200 mcg MOVANTIK TAB 12.5MG MOVANTIK TAB 25MG SUCRAID SOL 8500/ML sucralfate tab 1 gm ursodiol cap 300 mg ursodiol tab 250 mg ursodiol tab 500 mg XIFAXAN TAB 550MG $0 (1) $0-$6.60 $0-$6.60 $0 (1) $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 PANCREATIC ENZYMES CREON CAP 3000UNIT CREON CAP 6000UNIT CREON CAP 12000UNT $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 76 Drug Name (By Medical Condition) CREON CAP 24000UNT CREON CAP 36000UNT ZENPEP CAP 3000UNIT ZENPEP CAP 5000UNIT ZENPEP CAP 10000UNT ZENPEP CAP 15000UNT ZENPEP CAP 20000UNT ZENPEP CAP 25000UNT ZENPEP CAP 40000UNT WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH ACID DEXILANT CAP 30MG DR DEXILANT CAP 60MG DR esomepra mag cap 40mg dr esomeprazole magnesium cap delayed release 20 mg (base eq) esomeprazole sodium for intravenous soln 20 mg (base equiv) esomeprazole sodium for intravenous soln 40 mg (base equiv) NEXIUM CAP 20MG NEXIUM CAP 40MG NEXIUM GRA 2.5MG DR NEXIUM GRA 5MG DR NEXIUM GRA 10MG DR $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0 (1) NEXIUM GRA 20MG DR $0-$6.60 (2) NEXIUM GRA 40MG DR $0-$6.60 (2) omeprazole cap delayed release 10 mg omeprazole cap delayed release 20 mg omeprazole cap delayed release 40 mg pantoprazole sodium ec tab 20 mg (base equiv) pantoprazole sodium ec tab 40 mg (base equiv) $0 $0 $0 $0 QL QL QL QL (30 (30 (30 (30 caps caps caps caps / / / / 30 30 30 30 days) days) days) days) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) (2) (1) (1) (1) (1) $0 (1) QL (30 caps / 30 days) QL (30 caps / 30 days) QL (30 days) QL (30 days) QL (30 days) QL (30 QL (60 QL (30 QL (30 packets / 30 packets / 30 packets / 30 caps / 30 days) caps / 30 days) caps / 30 days) tabs / 30 days) QL (30 tabs / 30 days) GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED PROSTATE alfuzosin hcl tab sr 24hr 10 mg AVODART CAP 0.5MG $0 (1) $0-$6.60 (2) QL (30 tabs / 30 days) QL (30 caps / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 77 Drug Name (By Medical Condition) finasteride tab 5 mg JALYN CAP tamsulosin hcl cap 0.4 mg WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0-$6.60 (2) $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (30 caps / 30 days) QL (60 caps / 30 days) MISCELLANEOUS bethanechol chloride tab 5 mg bethanechol chloride tab 10 mg bethanechol chloride tab 25 mg bethanechol chloride tab 50 mg ELMIRON CAP 100MG POTASSIUM CITRATE TAB CR 5 MEQ (540 MG) POTASSIUM CITRATE TAB CR 10 MEQ (1080 MG) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0 (1) $0 (1) URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCE MYRBETRIQ TAB 25MG $0-$6.60 MYRBETRIQ TAB 50MG $0-$6.60 oxybutynin chloride syrup 5 mg/5ml $0 (1) oxybutynin chloride tab 5 mg $0 (1) oxybutynin chloride tab sr 24hr 5 mg $0 (1) oxybutynin chloride tab sr 24hr 10 mg $0 (1) oxybutynin chloride tab sr 24hr 15 mg $0 (1) TOLTERODINE TARTRATE CAP SR 24HR 2 $0 (1) MG TOLTERODINE TARTRATE CAP SR 24HR 4 $0 (1) MG tolterodine tartrate tab 1 mg $0 (1) tolterodine tartrate tab 2 mg $0 (1) TOVIAZ TAB 4MG $0-$6.60 TOVIAZ TAB 8MG $0-$6.60 trospium chloride tab 20 mg $0 (1) VESICARE TAB 5MG $0-$6.60 VESICARE TAB 10MG $0-$6.60 (2) (2) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL QL QL QL (30 (60 (60 (30 tabs / 30 days) tabs / 30 days) tabs / 30 days) caps / 30 days) QL (30 caps / 30 days) (2) (2) (2) (2) QL QL QL QL QL (30 (30 (60 (30 (30 tabs tabs tabs tabs tabs / / / / / 30 30 30 30 30 days) days) days) days) days) VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal cream 2% $0 (1) clotrimazole cre 1% vag $0 (3) clotrimazole cre 3 day $0 (3) CLOTRIMAZOLE CRE 3 DAY $0 (3) clotrimazole vaginal cream 1% $0 (3) 3 DAY VAGINL CRE 2% $0 (3) metronidazole vaginal gel 0.75% $0 (1) miconazole 3 kit combinat $0 (3) miconazole 3 kit combo pk $0 (3) NM; NM; NM; NM; NM; * * * * * NM; * NM; * PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 78 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) miconazole 7 cre 2% $0 (3) miconazole 7 cre tube/kit $0 (3) miconazole 7 sup 100mg $0 (3) miconazole nitrate vaginal cream 2% $0 (3) miconazole nitrate vaginal suppos 100 mg $0 (3) sm micon 7 sup 100mg $0 (3) terconazole vaginal cream 0.4% $0 (1) terconazole vaginal cream 0.8% $0 (1) terconazole vaginal suppos 80 mg $0 (1) tioconazole oin 6.5% vag $0 (3) VANDAZOLE GEL 0.75% $0 (1) zazole cre 0.4% $0 (1) ZAZOLE CRE 0.8% $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE NM; NM; NM; NM; NM; NM; * * * * * * NM; * HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS - BLOOD THINNERS COUMADIN TAB 1MG COUMADIN TAB 2.5MG COUMADIN TAB 2MG COUMADIN TAB 3MG COUMADIN TAB 4MG COUMADIN TAB 5MG COUMADIN TAB 6MG COUMADIN TAB 7.5MG COUMADIN TAB 10MG ELIQUIS TAB 2.5MG ELIQUIS TAB 5MG enoxaparin sodium inj 30 mg/0.3ml enoxaparin sodium inj 40 mg/0.4ml enoxaparin sodium inj 60 mg/0.6ml enoxaparin sodium inj 80 mg/0.8ml enoxaparin sodium inj 100 mg/ml enoxaparin sodium inj 120 mg/0.8ml enoxaparin sodium inj 150 mg/ml enoxaparin sodium inj 300 mg/3ml fondaparinux sodium subcutaneous inj mg/0.5ml fondaparinux sodium subcutaneous inj mg/0.4ml fondaparinux sodium subcutaneous inj mg/0.6ml fondaparinux sodium subcutaneous inj mg/0.8ml HEP SOD/D5W INJ 25000UNT $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) 2.5 $0 (1) 5 (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) $0-$6.60 (2) 7.5 $0-$6.60 (2) 10 $0-$6.60 (2) $0-$6.60 (2) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 79 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) HEP SOD/NACL INJ 25000UNT $0-$6.60 (2) HEPARIN SOD INJ 2000/ML $0-$6.60 (2) HEPARIN SOD INJ 2500/ML $0-$6.60 (2) HEPARIN SODIUM (PORCINE) 40 UNIT/ML $0-$6.60 (2) IN D5W heparin sodium (porcine) inj 1000 unit/ml $0 (1) heparin sodium (porcine) inj 5000 unit/ml $0 (1) heparin sodium (porcine) inj 10000 unit/ml$0 (1) heparin sodium (porcine) inj 20000 unit/ml$0 (1) jantoven tab 1mg $0 (1) jantoven tab 2.5mg $0 (1) jantoven tab 2mg $0 (1) jantoven tab 3mg $0 (1) jantoven tab 4mg $0 (1) jantoven tab 5mg $0 (1) jantoven tab 6mg $0 (1) jantoven tab 7.5mg $0 (1) jantoven tab 10mg $0 (1) PRADAXA CAP 75MG $0-$6.60 (2) PRADAXA CAP 150MG $0-$6.60 (2) warfarin sodium tab 1 mg $0 (1) warfarin sodium tab 2 mg $0 (1) warfarin sodium tab 2.5 mg $0 (1) warfarin sodium tab 3 mg $0 (1) warfarin sodium tab 4 mg $0 (1) warfarin sodium tab 5 mg $0 (1) warfarin sodium tab 6 mg $0 (1) warfarin sodium tab 7.5 mg $0 (1) warfarin sodium tab 10 mg $0 (1) XARELTO STAR TAB 15/20MG $0-$6.60 (2) XARELTO TAB 10MG $0-$6.60 (2) XARELTO TAB 15MG $0-$6.60 (2) XARELTO TAB 20MG $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE B/D B/D B/D B/D B/D B/D HEMATOPOIETIC GROWTH FACTORS GRANIX INJ 300/0.5 GRANIX INJ 480/0.8 LEUKINE INJ 250MCG MOZOBIL INJ NEUMEGA INJ 5MG NEUPOGEN INJ 300/0.5 NEUPOGEN INJ 300MCG NEUPOGEN INJ 480/0.8 NEUPOGEN INJ 480MCG $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) (2) (2) (2) (2) (2) NM, NM, NM, NM, NM NM, NM, NM, NM, PA PA PA PA PA PA PA PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 80 Drug Name (By Medical Condition) PROCRIT PROCRIT PROCRIT PROCRIT PROCRIT PROCRIT INJ INJ INJ INJ INJ INJ 2000/ML 3000/ML 4000/ML 10000/ML 20000/ML 40000/ML WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE NM, NM, NM, NM, NM, NM, PA PA PA PA PA PA $0 $0 $0 $0 $0 NM; NM; NM; NM; NM; * * * * * IRON cvs iron tab 325mg ferosul elx 220/5ml FERROUS SUL LIQ 220/5ML FERROUS SULF TAB 324MG EC ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ferrous sulfate tab 325 mg (65 mg elemental fe) ferrous sulfate tab ec 325 mg (65 mg fe equivalent) gnp iron tab 65mg iron supplem tab therapy iron therapy tab 200mg px iron tab 200mg (3) (3) (3) (3) (3) $0 (3) NM; * $0 (3) NM; * $0 $0 $0 $0 NM; NM; NM; NM; (3) (3) (3) (3) * * * * MISCELLANEOUS anagrelide hcl cap 0.5 mg anagrelide hcl cap 1 mg cilostazol tab 50 mg cilostazol tab 100 mg CINRYZE SOL 500 UNIT FIRAZYR INJ 30MG/3ML pentoxifylline tab cr 400 mg PROMACTA TAB 12.5MG $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0 (1) $0-$6.60 (2) PROMACTA TAB 25MG $0-$6.60 (2) PROMACTA TAB 50MG $0-$6.60 (2) PROMACTA TAB 75MG $0-$6.60 (2) tranexamic acid inj 100 mg/ml tranexamic acid tab 650 mg $0 (1) $0 (1) NM, LA, PA NM, PA QL (360 tabs / 30 days), NM, LA, PA QL (180 tabs / 30 days), NM, LA, PA QL (90 tabs / 30 days), NM, LA, PA QL (60 tabs / 30 days), NM, LA, PA PLATELET AGGREGATION INHIBITORS AGGRENOX CAP 25-200MG ASPIRIN-DIPYRIDAMOLE CAP SR 12HR 25-200 MG $0-$6.60 (2) $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 81 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) BRILINTA TAB 60MG $0-$6.60 (2) BRILINTA TAB 90MG $0-$6.60 (2) clopidogrel bisulfate tab 75 mg (base equiv)$0 (1) EFFIENT TAB 5MG $0-$6.60 (2) EFFIENT TAB 10MG $0-$6.60 (2) ZONTIVITY TAB 2.08MG $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (30 tabs / 30 days) IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRITIS CIMZIA KIT CIMZIA KIT STARTER CIMZIA PREFL KIT 200MG/ML HUMIRA INJ 10MG/0.2 HUMIRA KIT 20MG/0.4 HUMIRA KIT 40MG/0.8 HUMIRA PEN INJ 40MG/0.8 HUMIRA PEN INJ CROHNS HUMIRA PEN INJ PSORIASI hydroxychloroquine sulfate tab 200 mg leflunomide tab 10 mg leflunomide tab 20 mg methotrexate sodium tab 2.5 mg (base equiv) REMICADE INJ 100MG $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) (2) (2) (2) (2) (2) (2) (2) (2) $0-$6.60 (2) NM, NM, NM, NM, NM, NM, NM, NM, NM, PA PA PA PA PA PA PA PA PA NM, PA IMMUNOGLOBULINS BIVIGAM INJ 10% $0-$6.60 (2) NM, PA CARIMUNE NF INJ 3GM $0-$6.60 (2) NM, PA CARIMUNE NF INJ 6GM $0-$6.60 (2) NM, PA CARIMUNE NF INJ 12GM $0-$6.60 (2) NM, PA FLEBOGAMMA INJ 5% $0-$6.60 (2) NM, PA FLEBOGAMMA INJ 10/200ML $0-$6.60 (2) NM, PA FLEBOGAMMA INJ 20/400ML $0-$6.60 (2) NM, PA FLEBOGAMMA INJ DIF 5% $0-$6.60 (2) NM, PA FLEBOGAMMA INJ DIF 10% $0-$6.60 (2) NM, PA GAMASTAN S/D INJ $0-$6.60 (2) B/D, NM GAMMAGARD INJ 1GM/10ML $0-$6.60 (2) NM, PA GAMMAGARD INJ 2.5GM/25 $0-$6.60 (2) NM, PA GAMMAGARD INJ 5GM/50ML $0-$6.60 (2) NM, PA GAMMAGARD INJ 10GM/100 $0-$6.60 (2) NM, PA GAMMAGARD INJ 20GM/200 $0-$6.60 (2) NM, PA GAMMAGARD INJ 30GM/300 $0-$6.60 (2) NM, PA GAMMAGARD SD INJ 2.5GM HU $0-$6.60 (2) NM, PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 82 Drug Name (By Medical Condition) GAMMAGARD SD INJ 5GM HU GAMMAGARD SD INJ 10GM HU GAMMAKED INJ 1GM/10ML GAMMAKED INJ 2.5GM/25 GAMMAKED INJ 5GM/50ML GAMMAKED INJ 10GM/100 GAMMAKED INJ 20GM/200 GAMMAPLEX INJ 2.5GM GAMMAPLEX INJ 5GM GAMMAPLEX INJ 10GM GAMUNEX-C INJ 1GM/10ML GAMUNEX-C INJ 2.5GM/25 GAMUNEX-C INJ 5GM/50ML GAMUNEX-C INJ 10GM/100 GAMUNEX-C INJ 20GM/200 GAMUNEX-C INJ 40/400ML OCTAGAM INJ 1GM OCTAGAM INJ 2.5GM OCTAGAM INJ 2GM/20ML OCTAGAM INJ 5GM OCTAGAM INJ 10GM OCTAGAM INJ 25GM PRIVIGEN INJ 5 GRAMS PRIVIGEN INJ 10GRAMS PRIVIGEN INJ 20GRAMS PRIVIGEN INJ 40GRAMS WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 NM, LA, PA NM, PA B/D, NM B/D, NM B/D, NM B/D, NM NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, LA, PA NM, LA, PA NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA IMMUNOMODULATORS ACTIMMUNE INJ 2MU/0.5 ARCALYST INJ 220MG INTRON A INJ 10MU INTRON A INJ 18MU INTRON A INJ 25MU INTRON A INJ 50MU PEG-INTRON KIT 50MCG PEG-INTRON KIT 50MCG RP PEG-INTRON KIT 80MCG RP PEG-INTRON KIT 120 RP PEG-INTRON KIT 150 RP PEGINTRON KIT 80MCG PEGINTRON KIT 120MCG PEGINTRON KIT 150MCG REVLIMID CAP 2.5MG REVLIMID CAP 5MG (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 83 Drug Name (By Medical Condition) REVLIMID CAP 10MG REVLIMID CAP 15MG REVLIMID CAP 20MG REVLIMID CAP 25MG THALOMID CAP 50MG THALOMID CAP 100MG THALOMID CAP 150MG THALOMID CAP 200MG WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE NM, NM, NM, NM, NM, NM, NM, NM, LA, LA, LA, LA, PA PA PA PA PA PA PA PA IMMUNOSUPPRESSANTS azathioprine tab 50 mg $0 (1) B/D cyclosporine cap 25 mg $0 (1) B/D cyclosporine cap 100 mg $0 (1) B/D cyclosporine iv soln 50 mg/ml $0 (1) B/D cyclosporine modified cap 25 mg $0 (1) B/D cyclosporine modified cap 50 mg $0 (1) B/D cyclosporine modified cap 100 mg $0 (1) B/D cyclosporine modified oral soln 100 mg/ml $0 (1) B/D gengraf cap 25mg $0 (1) B/D gengraf cap 100mg $0 (1) B/D gengraf sol 100mg/ml $0 (1) B/D mycophenolate mofetil cap 250 mg $0 (1) B/D mycophenolate mofetil for oral susp 200 $0-$6.60 (2) B/D mg/ml mycophenolate mofetil tab 500 mg $0 (1) B/D mycophenolate sodium tab dr 180 mg $0 (1) B/D (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg $0-$6.60 (2) B/D (mycophenolic acid equiv) NEORAL CAP 25MG $0-$6.60 (2) B/D NEORAL CAP 100MG $0-$6.60 (2) B/D NEORAL SOL 100MG/ML $0-$6.60 (2) B/D NULOJIX INJ 250MG $0-$6.60 (2) B/D PROGRAF CAP 0.5MG $0-$6.60 (2) B/D PROGRAF CAP 1MG $0-$6.60 (2) B/D PROGRAF CAP 5MG $0-$6.60 (2) B/D RAPAMUNE SOL 1MG/ML $0-$6.60 (2) B/D SANDIMMUNE CAP 25MG $0-$6.60 (2) B/D SANDIMMUNE CAP 100MG $0-$6.60 (2) B/D SANDIMMUNE SOL 100MG/ML $0-$6.60 (2) B/D sirolimus tab 0.5 mg $0 (1) B/D SIROLIMUS TAB 1 MG $0 (1) B/D SIROLIMUS TAB 2 MG $0-$6.60 (2) B/D tacrolimus cap 0.5 mg $0 (1) B/D tacrolimus cap 1 mg $0 (1) B/D PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 84 Drug Name (By Medical Condition) tacrolimus cap 5 mg ZORTRESS TAB 0.5MG ZORTRESS TAB 0.25MG ZORTRESS TAB 0.75MG WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE B/D B/D B/D B/D VACCINES ACTHIB INJ $0-$6.60 (2) ADACEL INJ $0-$6.60 (2) BCG VACCINE INJ $0-$6.60 (2) BEXSERO INJ $0-$6.60 (2) BOOSTRIX INJ $0-$6.60 (2) CERVARIX INJ $0-$6.60 (2) COMVAX INJ $0-$6.60 (2) DAPTACEL INJ $0-$6.60 (2) DIP/TET PED INJ 25-5LFU $0-$6.60 (2) B/D ENGERIX-B INJ 10/0.5ML $0-$6.60 (2) B/D ENGERIX-B INJ 20MCG/ML $0-$6.60 (2) B/D GARDASIL 9 INJ $0-$6.60 (2) GARDASIL INJ $0-$6.60 (2) HAVRIX INJ 720UNIT $0-$6.60 (2) HAVRIX INJ 1440UNIT $0-$6.60 (2) HIBERIX SOL 10MCG $0-$6.60 (2) IMOVAX RABIE INJ 2.5/ML $0-$6.60 (2) INFANRIX INJ $0-$6.60 (2) IPOL INJ INACTIVE $0-$6.60 (2) IXIARO INJ $0-$6.60 (2) KINRIX INJ $0-$6.60 (2) M-M-R II INJ $0-$6.60 (2) MENACTRA INJ $0-$6.60 (2) MENOMUNE INJ A/C/Y/W $0-$6.60 (2) MENVEO INJ $0-$6.60 (2) PEDVAX HIB INJ $0-$6.60 (2) PROQUAD INJ $0-$6.60 (2) QUADRACEL INJ $0-$6.60 (2) RABAVERT INJ $0-$6.60 (2) RECOMBIVA HB INJ 5MCG/0.5 $0-$6.60 (2) B/D RECOMBIVA HB INJ 10MCG/ML $0-$6.60 (2) B/D RECOMBIVA-HB INJ 40MCG/ML $0-$6.60 (2) B/D ROTARIX SUS $0-$6.60 (2) ROTATEQ SOL $0-$6.60 (2) SYNAGIS INJ 50MG $0-$6.60 (2) NM SYNAGIS INJ 100MG/ML $0-$6.60 (2) NM TENIVAC INJ 5-2LF $0-$6.60 (2) B/D TET/DIP TOX INJ 2-2 LF $0-$6.60 (2) B/D PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 85 Drug Name (By Medical Condition) TETANUS TOX INJ 5LF ADS TRUMENBA INJ TWINRIX INJ TYPHIM VI INJ VAQTA INJ 25/0.5ML VAQTA INJ 50UNT/ML VARIVAX INJ YF-VAX INJ ZOSTAVAX INJ WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE B/D QL (1 vial per lifetime) NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ELECTROLYTES cvs electrol sol $0 (3) gnp pediatri sol electrol $0 (3) KLOR-CON 8 TAB 8MEQ ER $0 (1) KLOR-CON 10 TAB 10MEQ ER $0 (1) klor-con m15 tab 15meq er $0 (1) klor-con pow 20meq $0 (1) MAGNESIUM SU INJ 20/500ML $0-$6.60 MAGNESIUM SU INJ 80MG/ML $0-$6.60 magnesium sulfate inj 50% $0 (1) MAGNESIUM SULFATE INJ 50% $0 (1) MG SO4/D5W INJ 10MG/ML $0-$6.60 MG SO4/D5W INJ 20MG/ML $0-$6.60 oral electrolyte solution $0 (3) oralyte sol $0 (3) ped elctrlyt sol fruit $0 (3) ped elctrlyt sol unflavrd $0 (3) potassium chloride cap cr 8 meq $0 (1) potassium chloride cap cr 10 meq $0 (1) potassium chloride microencapsulated crys $0 (1) cr tab 10 meq potassium chloride microencapsulated crys $0 (1) cr tab 20 meq potassium chloride oral soln 10% (20 $0 (1) meq/15ml) potassium chloride oral soln 20% (40 $0 (1) meq/15ml) potassium chloride tab cr 8 meq (600 mg) $0 (1) POTASSIUM CHLORIDE TAB CR 10 MEQ $0 (1) POTASSIUM CHLORIDE TAB CR 20 MEQ $0 (1) (1500 MG) SODIUM CHLORIDE INJ 2.5 MEQ/ML $0 (1) (14.6%) NM; * NM; * (2) (2) (2) (2) NM; NM; NM; NM; * * * * PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 86 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F)$0 (1) MG/ML SOLN TPN ELECTROL INJ $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE B/D IV NUTRITION amino acid infusion 6% AMINOSYN 7% INJ /LYTES AMINOSYN II INJ 7% AMINOSYN II INJ 8.5% AMINOSYN II INJ 8.5/LYTE AMINOSYN II INJ 10% AMINOSYN INJ 8.5% AMINOSYN INJ 8.5/LYTE AMINOSYN INJ 10% AMINOSYN M INJ 3.5% AMINOSYN-HBC INJ 7% AMINOSYN-PF INJ 7% AMINOSYN-PF INJ 10% AMINOSYN-RF INJ 5.2% CLINIMIX INJ 2.75/D5W CLINIMIX INJ 4.25/D5W CLINIMIX INJ 4.25/D10 CLINIMIX INJ 4.25/D20 CLINIMIX INJ 4.25/D25 CLINIMIX INJ 5%/D15W CLINIMIX INJ 5%/D20W CLINIMIX INJ 5%/D25W FAT EMULSION IV SOLN 20% FREAMINE HBC INJ 6.9% FREAMINE III INJ 10% HEPATAMINE SOL 8% INTRALIPID INJ 20% INTRALIPID INJ 30% NEPHRAMINE INJ 5.4% premasol sol 10% PROCALAMINE INJ 3% PROSOL INJ 20% travasol inj 10% TROPHAMINE INJ 10% $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D IV REPLACEMENT SOLUTIONS D5W/LYTES INJ #48 D5W/NACL INJ 0.3% D10W/NACL INJ 0.2% $0-$6.60 (2) $0 (1) $0-$6.60 (2) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 87 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) DEXTROSE 2.5% W/ SODIUM CHLORIDE 0.45% DEXTROSE 5% IN LACTATED RINGERS $0 (1) DEXTROSE 5% W/ SODIUM CHLORIDE $0 (1) 0.2% DEXTROSE 5% W/ SODIUM CHLORIDE $0 (1) 0.9% DEXTROSE 5% W/ SODIUM CHLORIDE $0 (1) 0.33% DEXTROSE 5% W/ SODIUM CHLORIDE $0 (1) 0.45% DEXTROSE 5% W/ SODIUM CHLORIDE $0 (1) 0.225% DEXTROSE 10% W/ SODIUM CHLORIDE $0 (1) 0.45% DEXTROSE INJ 5% $0 (1) DEXTROSE INJ 10% $0 (1) DEXTROSE INJ 50% $0 (1) dextrose inj 70% $0 (1) IONOSOL-B/ INJ D5W $0-$6.60 IONOSOL-MB INJ /D5W $0-$6.60 ISOLYTE-P INJ /D5W $0-$6.60 isolyte-s inj $0-$6.60 KCL 10 MEQ/L (0.075%) IN DEXTROSE 5%$0 (1) & NACL 0.45% INJ KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% &$0 (1) NACL 0.2% INJ KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% &$0 (1) NACL 0.9% INJ KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% &$0 (1) NACL 0.33% INJ KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% &$0 (1) NACL 0.45% INJ KCL 20 MEQ/L (0.15%) IN NACL 0.9% INJ $0 (1) kcl 20 meq/l (0.15%) in nacl 0.45% inj $0 (1) KCL 20 MEQ/L (0.15%) IN NACL 0.45% INJ$0 (1) KCL 30 MEQ/L (0.224%) IN DEXTROSE 5%$0 (1) & NACL 0.45% INJ KCL 40 MEQ/L (0.3%) IN DEXTROSE 5% & $0 (1) NACL 0.45% INJ KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ $0 (1) KCL/D5W/NACL INJ 0.3/0.9% $0 (1) KCL/D5W/NACL INJ 0.15/0.2 $0-$6.60 LACTATED RINGER'S SOLUTION $0 (1) (2) (2) (2) (2) (2) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 88 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) normosol -m inj /d5w $0 (1) NORMOSOL -R INJ /D5W $0-$6.60 (2) NORMOSOL-R INJ PH 7.4 $0-$6.60 (2) PLASMA-LYTE INJ 56/D5W $0-$6.60 (2) PLASMA-LYTE INJ -148 $0-$6.60 (2) PLASMA-LYTE INJ -A $0-$6.60 (2) POTASSIUM CHLORIDE 20 MEQ/L (0.15%) $0 (1) IN DEXTROSE 5% INJ POTASSIUM CHLORIDE 40 MEQ/L (0.3%) $0 (1) IN DEXTROSE 5% INJ potassium chloride inj 2 meq/ml $0 (1) potassium chloride inj 10 meq/50 ml $0 (1) POTASSIUM CHLORIDE INJ 10 MEQ/100 ML$0 (1) potassium chloride inj 20 meq/50 ml $0 (1) POTASSIUM CHLORIDE INJ 20 MEQ/100 ML$0 (1) potassium chloride inj 40 meq/100 ml $0 (1) RINGER'S SOLUTION $0 (1) SODIUM CHLORIDE INJ 0.45% $0 (1) SODIUM CHLORIDE INJ 3% $0 (1) SODIUM CHLORIDE INJ 5% $0 (1) SODIUM CHLORIDE IV SOLN 0.9% $0 (1) VITAMINS calcitriol cap 0.5 mcg $0 calcitriol cap 0.25 mcg $0 calcitriol inj 1 mcg/ml $0 calcitriol oral soln 1 mcg/ml $0 paricalcitol cap 1 mcg $0 paricalcitol cap 2 mcg $0 paricalcitol cap 4 mcg $0 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG $0 (GENERIC) (1) (1) (1) (1) (1) (1) (1) (1) B/D B/D B/D B/D B/D B/D B/D OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION bacitracin-polymyxin-neomycin-hc ophth oint 1% blephamide oin s.o.p. neomycin-polymyxin-dexamethasone ophth oint 0.1% neomycin-polymyxin-dexamethasone ophth susp 0.1% neomycin-polymyxin-hc ophth susp $0 (1) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 89 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) sulfacetamide sodium-prednisolone ophth $0 (1) soln 10-0.23(0.25)% TOBRADEX OIN 0.3-0.1% $0-$6.60 (2) TOBRADEX ST SUS 0.3-0.05 $0-$6.60 (2) tobramycin-dexamethasone ophth susp $0 (1) 0.3-0.1% ZYLET SUS 0.5-0.3% $0-$6.60 (2) ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS bacitracin ophth oint 500 unit/gm bacitracin-polymyxin b ophth oint BESIVANCE SUS 0.6% CILOXAN OIN 0.3% OP ciprofloxacin hcl ophth soln 0.3% erythromycin ophth oint 5 mg/gm gatifloxacin ophth soln 0.5% gentak oin 0.3% op gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% ilotycin oin op MOXEZA SOL 0.5% NATACYN SUS 5% OP neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml ofloxacin ophth soln 0.3% polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% sulfacetamide sodium ophth oint 10% sulfacetamide sodium ophth soln 10% tobramycin ophth soln 0.3% TOBREX OIN 0.3% OP trifluridine ophth soln 1% VIGAMOX DRO 0.5% $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0 (1) (2) (2) (2) (2) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0 (1) $0-$6.60 (2) ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION ALREX SUS 0.2% $0-$6.60 (2) BROMFENAC SODIUM OPHTH SOLN 0.09% $0 (1) (BASE EQUIV) (ONCE-DAILY) bromfenac sodium ophth soln 0.09% (base$0 (1) equivalent) dexamethasone sodium phosphate ophth $0 (1) soln 0.1% diclofenac sodium ophth soln 0.1% $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 90 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) DUREZOL EMU 0.05% $0-$6.60 (2) FLUOROMETHOLONE OPHTH SUSP 0.1% $0 (1) flurbiprofen sodium ophth soln 0.03% $0 (1) ILEVRO DRO 0.3% OP $0-$6.60 (2) ketorolac tromethamine ophth soln 0.4% $0 (1) ketorolac tromethamine ophth soln 0.5% $0 (1) LOTEMAX GEL 0.5% $0-$6.60 (2) LOTEMAX OIN 0.5% $0-$6.60 (2) LOTEMAX SUS 0.5% $0-$6.60 (2) MAXIDEX SUS 0.1% OP $0-$6.60 (2) NEVANAC SUS 0.1% $0-$6.60 (2) pred sod pho sol 1% op $0-$6.60 (2) PREDNISOLONE ACETATE OPHTH SUSP 1%$0 (1) ANTIALLERGICS - DRUGS TO TREAT ALLERGIES azelastine hcl ophth soln 0.05% BEPREVE DRO 1.5% cromolyn sodium ophth soln 4% LASTACAFT SOL 0.25% PATADAY SOL 0.2% PATANOL SOL 0.1% OP PAZEO DRO 0.7% $0 (1) $0-$6.60 $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) (2) ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA ALPHAGAN P SOL 0.1% $0-$6.60 AZOPT SUS 1% OP $0-$6.60 betaxolol hcl ophth soln 0.5% $0 (1) BETOPTIC-S SUS 0.25% OP $0-$6.60 brimonidine tartrate ophth soln 0.2% $0 (1) BRIMONIDINE TARTRATE OPHTH SOLN $0 (1) 0.15% carteolol hcl ophth soln 1% $0 (1) COMBIGAN SOL 0.2/0.5% $0-$6.60 dorzolamide hcl ophth soln 2% $0 (1) dorzolamide hcl-timolol maleate ophth soln$0 (1) 22.3-6.8 mg/ml ISTALOL SOL 0.5% OP $0-$6.60 latanoprost ophth soln 0.005% $0 (1) levobunolol hcl ophth soln 0.5% $0 (1) LEVOBUNOLOL HCL OPHTH SOLN 0.25% $0 (1) LUMIGAN SOL 0.01% $0-$6.60 metipranolol ophth soln 0.3% $0 (1) PHOSPHOLINE SOL 0.125%OP $0-$6.60 PILOCARPINE HCL OPHTH SOLN 1% $0 (1) (2) (2) (2) (2) (2) (2) (2) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 91 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) PILOCARPINE HCL OPHTH SOLN 2% $0 (1) PILOCARPINE HCL OPHTH SOLN 4% $0 (1) SIMBRINZA SUS 1-0.2% $0-$6.60 (2) TIMOLOL MALEATE OPHTH GEL FORMING $0 (1) SOLN 0.5% TIMOLOL MALEATE OPHTH GEL FORMING $0 (1) SOLN 0.25% timolol maleate ophth soln 0.5% $0 (1) timolol maleate ophth soln 0.25% $0 (1) TRAVATAN Z DRO 0.004% $0-$6.60 (2) MISCELLANEOUS akwa tears oin op artifi tears oin op artifi tears sol 1.4% op artifi tears sol op artificial sol tears GENTEAL GEL 0.3% ISOPTO TEARS SOL 0.5% OP liquitears sol lubricant dro eye lubrifresh oin p.m. MURO 128 SOL 2% OP naphazoline hcl ophth soln 0.1% natural bal sol 0.4% natures tear sol 0.4% optics mini dro PROLENSA SOL 0.07% proparacaine hcl ophth soln 0.5% pure & gentl dro 0.3% REFRESH CELL DRO 1% OP refresh lacr oin op REFRESH LIQU DRO 1% OP RESTASIS EMU 0.05% retaine cmc sol 0.5% op sm artificia sol tears sodium chloride hypertonic ophth oint 5% sodium chloride hypertonic ophth soln 5% SYSTANE PF SOL tears natura sol ii op tears pure sol $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (1) $0 (3) $0 (3) $0 (3) $0-$6.60 (2) $0 (1) $0 (3) $0 (3) $0 (3) $0 (3) $0-$6.60 (2) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; * * * * * * * * * * * NM; * NM; * NM; * NM; * NM; * NM; * NM; * QL (64 vials / 30 days) NM; * NM; * NM; * NM; * NM; * NM; * NM; * RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO TREAT COPD PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 92 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) ANORO ELLIPT AER 62.5-25 $0-$6.60 (2) COMBIVENT AER RESPIMAT $0-$6.60 (2) ipratropium-albuterol nebu soln 0.5-2.5(3) $0 (1) mg/3ml NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE QL (1 inhaler / 30 days) QL (2 inhalers / 30 days) B/D ANTICHOLINERGICS - DRUGS TO TREAT COPD ATROVENT HFA AER 17MCG $0-$6.60 ipratropium bromide inhal soln 0.02% $0 (1) ipratropium bromide nasal soln 0.03% (21 $0 (1) mcg/spray) ipratropium bromide nasal soln 0.06% (42 $0 (1) mcg/spray) SPIRIVA CAP HANDIHLR $0-$6.60 SPIRIVA SPR RESPIMAT $0-$6.60 TUDORZA PRES AER 400/ACT $0-$6.60 TUDORZA PRES AER 400/ACT $0-$6.60 (2) QL (2 inhalers / 30 days) B/D (2) (2) (2) (2) QL QL QL QL (30 caps / 30 days) (1 inhaler / 30 days) (1 inhaler / 30 days) (2 inhalers / 30 days) ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES ASTEPRO SPR 0.15% $0-$6.60 azelastine hcl nasal spray 0.1% (137 $0 (1) mcg/spray) azelastine hcl nasal spray 0.15% (205.5 $0 (1) mcg/spray) cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)$0 (1) diphenhydramine hcl inj 50 mg/ml $0 (1) hydroxyzine hcl im soln 25 mg/ml $0-$6.60 hydroxyzine hcl im soln 50 mg/ml $0-$6.60 hydroxyzine hcl syrup 10 mg/5ml $0-$6.60 (2) (2) (2) (2) hydroxyzine hcl tab 10 mg $0-$6.60 (2) hydroxyzine hcl tab 25 mg $0-$6.60 (2) hydroxyzine hcl tab 50 mg $0-$6.60 (2) hydroxyzine pamoate cap 25 mg $0-$6.60 (2) hydroxyzine pamoate cap 50 mg $0-$6.60 (2) hydroxyzine pamoate cap 100 mg $0-$6.60 (2) levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg olopatadine hcl nasal soln 0.6% $0 (1) PA PA PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older PA; PA older for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or for age 65 or $0 (1) $0 (1) BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPD PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 93 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) albuterol sulfate soln nebu 0.5% (5 mg/ml)$0 (1) albuterol sulfate soln nebu 0.63 mg/3ml $0 (1) (base equiv) albuterol sulfate soln nebu 0.083% (2.5 $0 (1) mg/3ml) albuterol sulfate soln nebu 1.25 mg/3ml $0 (1) (base equiv) albuterol sulfate syrup 2 mg/5ml $0 (1) albuterol sulfate tab 2 mg $0 (1) albuterol sulfate tab 4 mg $0 (1) albuterol sulfate tab sr 12hr 4 mg $0 (1) albuterol sulfate tab sr 12hr 8 mg $0 (1) FORADIL CAP AEROLIZE $0-$6.60 (2) levalbuterol hcl soln nebu conc 1.25 $0 (1) mg/0.5ml (base equiv) PERFOROMIST NEB 20MCG $0-$6.60 (2) PROAIR HFA AER $0-$6.60 (2) SEREVENT DIS AER 50MCG $0-$6.60 (2) terbutaline sulfate inj 1 mg/ml $0 (1) terbutaline sulfate tab 2.5 mg $0 (1) terbutaline sulfate tab 5 mg $0 (1) XOPENEX HFA AER $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE B/D B/D B/D B/D QL (60 caps / 30 days) B/D B/D QL (2 inhalers / 30 days) QL (1 inhaler / 30 days) QL (2 inhalers / 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS - DRUGS TO TREAT ASTHMA AND ALLERGIES montelukast sodium chew tab 4 mg (base $0 equiv) montelukast sodium chew tab 5 mg (base $0 equiv) montelukast sodium oral granules packet 4$0 mg (base equiv) montelukast sodium tab 10 mg (base $0 equiv) zafirlukast tab 10 mg $0 zafirlukast tab 20 mg $0 (1) (1) (1) (1) (1) (1) MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIES cromolyn sodium soln nebu 20 mg/2ml $0 (1) B/D $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 B/D B/D NM, NM, NM, NM, MISCELLANEOUS acetylcysteine inhal soln 10% acetylcysteine inhal soln 20% ARALAST NP INJ 400MG ARALAST NP INJ 500MG ARALAST NP INJ 800MG ARALAST NP INJ 1000MG (2) (2) (2) (2) LA, LA, LA, LA, PA PA PA PA PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 94 Drug Name (By Medical Condition) AUVI-Q INJ 0.3MG AUVI-Q INJ 0.15MG AYR NASAL DRO 0.65% ayr spr 0.65% DALIRESP TAB 500MCG deep sea spr 0.65% EPIPEN 2-PAK INJ 0.3MG EPIPEN-JR INJ 2-PAK hm saline spr 0.65% nasal moist spr 0.65% nasal saline spr 0.65% ORKAMBI TAB 200-125 PROLASTIN-C INJ 1000MG PULMOZYME SOL 1MG/ML saline mist spr 0.65% saline nasal spr 0.65% saline nasal spray 0.65% sb saline spr 0.65% sea soft spr 0.65% XOLAIR SOL 150MG ZEMAIRA INJ 1000MG WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0-$6.60 (2) $0-$6.60 (2) $0 (3) $0 (3) $0-$6.60 (2) $0 (3) $0-$6.60 (2) $0-$6.60 (2) $0 (3) $0 (3) $0 (3) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0-$6.60 (2) $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE NM; * NM; * NM; * NM; * NM; * NM; * NM, PA NM, LA, PA B/D, NM NM; * NM; * NM; * NM; * NM; * NM, LA, PA NM, LA, PA NASAL STEROIDS - DRUGS TO TREAT ALLERGIES flunisolide nasal soln 25 mcg/act (0.025%)$0 (1) fluticasone propionate nasal susp 50 $0 (1) mcg/act NASONEX SPR 50MCG/AC $0-$6.60 (2) QL (2 bottles / 30 days) QL (1 bottle / 30 days) QL (2 bottles / 30 days) STEROID INHALANTS - DRUGS TO TREAT ASTHMA ASMANEX 14 AER 220MCG ASMANEX 30 AER 110MCG ASMANEX 30 AER 220MCG ASMANEX 60 AER 220MCG ASMANEX 120 AER 220MCG budesonide inhalation susp 0.5 mg/2ml budesonide inhalation susp 0.25 mg/2ml FLOVENT DISK AER 50MCG FLOVENT DISK AER 100MCG FLOVENT DISK AER 250MCG FLOVENT HFA AER 44MCG FLOVENT HFA AER 110MCG FLOVENT HFA AER 220MCG QVAR AER 40MCG QVAR AER 80MCG $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) QL (2 QL (2 QL (2 QL (2 QL (2 B/D B/D QL (2 QL (2 QL (4 QL (2 QL (2 QL (2 QL (1 QL (2 inhalers inhalers inhalers inhalers inhalers / / / / / 30 30 30 30 30 days) days) days) days) days) inhalers / 30 days) inhalers / 30 days) inhalers / 30 days) inhalers / 30 days) inhalers / 30 days) inhalers / 30 days) inhaler / 30 days) inhalers / 30 days) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 95 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT ASTHMA AND COPD ADVAIR DISKU AER 100/50 ADVAIR DISKU AER 250/50 ADVAIR DISKU AER 500/50 ADVAIR HFA AER 45/21 ADVAIR HFA AER 115/21 ADVAIR HFA AER 230/21 BREO ELLIPTA INH 100-25 BREO ELLIPTA INH 200-25 DULERA AER 100-5MCG DULERA AER 200-5MCG SYMBICORT AER 80-4.5 SYMBICORT AER 160-4.5 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) QL QL QL QL QL QL QL QL QL QL QL QL (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 (1 inhaler inhaler inhaler inhaler inhaler inhaler inhaler inhaler inhaler inhaler inhaler inhaler / / / / / / / / / / / / 30 30 30 30 30 30 30 30 30 30 30 30 days) days) days) days) days) days) days) days) days) days) days) days) XANTHINES - DRUGS TO TREAT COPD aminophylline inj 25 mg/ml elixophyllin elx 80/15ml theo-24 cap 100mg cr theo-24 cap 200mg cr theo-24 cap 300mg cr theo-24 cap 400mg er theophylline soln 80 mg/15ml theophylline tab sr 12hr 100 mg theophylline tab sr 12hr 200 mg theophylline tab sr 12hr 300 mg theophylline tab sr 12hr 450 mg theophylline tab sr 24hr 400 mg theophylline tab sr 24hr 600 mg TOPICAL - DRUGS TO TREAT EAR DERMATOLOGY, ACNE adapalene cream 0.1% adapalene gel 0.1% amnesteem cap 10mg amnesteem cap 20mg amnesteem cap 40mg AVITA CRE 0.025% AVITA GEL 0.025% benzoyl peroxide-erythromycin gel 5-3% claravis cap 10mg claravis cap 20mg claravis cap 30mg claravis cap 40mg $0 (1) $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0-$6.60 $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) (2) (2) (2) (2) (2) AND SKIN CONDITIONS $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 96 Drug Name (By Medical Condition) clindamax gel 1% clindamycin phosphate gel 1% clindamycin phosphate lotion 1% clindamycin phosphate soln 1% clindamycin phosphate swab 1% erythromycin gel 2% erythromycin pads 2% erythromycin soln 2% myorisan cap 10mg myorisan cap 20mg myorisan cap 40mg sulfacetamide sodium lotion 10% (acne) tretinoin cream 0.1% tretinoin cream 0.05% tretinoin cream 0.025% tretinoin gel 0.01% tretinoin gel 0.025% zenatane cap 10mg zenatane cap 20mg zenatane cap 30mg zenatane cap 40mg WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) $0 (1) DERMATOLOGY, ANTIBIOTICS antibiotic cre plus $0 (3) NM; * bacitr zinc oin 500/gm $0 (3) NM; * bacitracin oin 500/gm $0 (3) NM; * bacitracin oint 500 unit/gm $0 (3) NM; * bacitracin zinc oint 500 unit/gm $0 (3) NM; * double antib oin $0 (3) NM; * gentamicin sulfate cream 0.1% $0 (1) gentamicin sulfate oint 0.1% $0 (1) gnp triple oin antibiot $0 (3) NM; * hm triple oin antibiot $0 (3) NM; * mupirocin oint 2% $0 (1) neomycin-bacitracin-polymyxin oint $0 (3) NM; * sb triple oin antibiot $0 (3) NM; * SILVER SULFADIAZINE CREAM 1% $0 (1) sm first aid oin 500/gm $0 (3) NM; * sm triple oin antibiot $0 (3) NM; * SSD CRE 1% $0 (1) SULFAMYLON CRE 85MG/GM $0-$6.60 (2) triple antib oin $0 (3) NM; * triple antib oin max st $0 (3) NM; * triple antib oin plus $0 (3) NM; * PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 97 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) DERMATOLOGY, ANTIFUNGALS antifungal cre 2% $0 athlete foot cre 1% $0 baza antifun cre 2% $0 ciclopirox gel 0.77% $0 ciclopirox olamine cream 0.77% (base $0 equiv) ciclopirox olamine susp 0.77% (base equiv)$0 ciclopirox shampoo 1% $0 clotrimazole cre 1% $0 clotrimazole cream 1% $0 clotrimazole soln 1% $0 critic-aid oin 2% $0 desenex aer 2% $0 desenex shak pow 2% $0 econazole nitrate cream 1% $0 fungicure spr intens $0 FUNGOID TINC SOL 2% $0 ketoconazole cream 2% $0 miconazole nitrate cream 2% $0 miconazorb pow af 2% $0 micro guard pow 2% $0 mitrazol pow 2% $0 nyamyc pow 100000 $0 nystatin cream 100000 unit/gm $0 nystatin oint 100000 unit/gm $0 nystatin topical powder $0 nystop pow 100000 $0 remedy pow antifung $0 sm antifungl cre 2% $0 terbinafine cre 1% $0 terbinafine hcl cream 1% $0 zeasorb-af pow 2% $0 (3) (3) (3) (1) (1) (1) (1) (3) (1) (1) (3) (3) (3) (1) (3) (3) (1) (3) (3) (3) (3) (1) (1) (1) (1) (1) (3) (3) (3) (3) (3) NM; * NM; * NM; * NM; * NM; * NM; * NM; * NM; * NM; * NM; NM; NM; NM; * * * * NM; NM; NM; NM; NM; * * * * * DERMATOLOGY, ANTIPRURITIC hydrocortisone rectal cream 2.5% procto-pak cre 1% proctozone cre -hc 2.5% PRUDOXIN CRE 5% $0 $0 $0 $0 (1) (1) (1) (1) DERMATOLOGY, ANTIPSORIATICS acitretin cap 10 mg $0-$6.60 (2) PA acitretin cap 17.5 mg $0-$6.60 (2) PA acitretin cap 25 mg $0-$6.60 (2) PA calcipotriene cream 0.005% $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 98 Drug Name (By Medical Condition) calcipotriene oint 0.005% calcipotriene soln 0.005% (50 mcg/ml) calcitrene oin 0.005% 8-MOP CAP 10MG TAZORAC CRE 0.1% TAZORAC CRE 0.05% WHAT THE DRUG WILL COST YOU (TIER LEVEL) $0 (1) $0 (1) $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0-$6.60 (2) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE PA PA DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 2% selenium sulfide lotion 2.5% $0 (1) $0 (1) DERMATOLOGY, ANTIVIRALS acyclovir oint 5% DENAVIR CRE 1% $0 (1) $0-$6.60 (2) DERMATOLOGY, CORTICOSTEROIDS ala cort cre 1% $0 (1) alclometasone dipropionate cream 0.05% $0 (1) alclometasone dipropionate oint 0.05% $0 (1) amcinonide cream 0.1% $0 (1) amcinonide lotion 0.1% $0 (1) amcinonide oin 0.1% $0-$6.60 (2) betamethasone dipropionate augmented $0 (1) cream 0.05% betamethasone dipropionate augmented $0 (1) gel 0.05% betamethasone dipropionate augmented $0 (1) lotion 0.05% betamethasone dipropionate augmented $0 (1) oint 0.05% betamethasone dipropionate cream 0.05% $0 (1) betamethasone dipropionate lotion 0.05% $0 (1) betamethasone dipropionate oint 0.05% $0 (1) betamethasone valerate cream 0.1% $0 (1) betamethasone valerate lotion 0.1% $0 (1) betamethasone valerate oint 0.1% $0 (1) clobetasol e cre 0.05% $0 (1) clobetasol propionate cream 0.05% $0 (1) clobetasol propionate gel 0.05% $0 (1) clobetasol propionate oint 0.05% $0 (1) clobetasol propionate soln 0.05% $0 (1) cormax scalp sol 0.05% $0 (1) DESONIDE CREAM 0.05% $0 (1) desonide lotion 0.05% $0 (1) desonide oint 0.05% $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 99 Drug Name (By Medical Condition) WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) desoximetasone cream 0.05% $0 (1) desoximetasone cream 0.25% $0 (1) desoximetasone gel 0.05% $0 (1) DESOXIMETASONE OINT 0.05% $0 (1) desoximetasone oint 0.25% $0 (1) diflorasone diacetate cream 0.05% $0 (1) diflorasone diacetate oint 0.05% $0 (1) fluocin acet oil scalp $0 (1) fluocinolone acetonide cream 0.01% $0 (1) fluocinolone acetonide cream 0.025% $0 (1) fluocinolone acetonide oil 0.01% (body oil) $0 (1) fluocinolone acetonide oint 0.025% $0 (1) fluocinolone acetonide soln 0.01% $0 (1) fluocinonide cream 0.05% $0 (1) fluocinonide emulsified base cream 0.05% $0 (1) fluocinonide gel 0.05% $0 (1) fluocinonide oint 0.05% $0 (1) fluocinonide soln 0.05% $0 (1) fluticasone propionate cream 0.05% $0 (1) fluticasone propionate oint 0.005% $0 (1) halobetasol propionate cream 0.05% $0 (1) halobetasol propionate oint 0.05% $0 (1) hydro skin lot 1% $0 (3) NM; * hydrocort cre 0.5% $0 (3) NM; * hydrocort/ cre aloe 1% $0 (3) NM; * hydrocortisone butyrate cream 0.1% $0 (1) hydrocortisone butyrate oint 0.1% $0 (1) hydrocortisone butyrate soln 0.1% $0 (1) hydrocortisone cream 0.5% $0 (3) NM; * hydrocortisone cream 1% $0 (1) hydrocortisone cream 1% $0 (3) NM; * hydrocortisone cream 2.5% $0 (1) hydrocortisone lotion 1% $0 (3) NM; * hydrocortisone lotion 2.5% $0 (1) hydrocortisone oint 1% $0 (1) hydrocortisone oint 1% $0 (3) NM; * hydrocortisone oint 2.5% $0 (1) hydrocortisone valerate cream 0.2% $0 (1) hydrocortisone valerate oint 0.2% $0 (1) hydrocortisone-aloe vera cream 0.5% $0 (3) NM; * LOKARA LOT 0.05% $0 (1) medi-cort cre 1% $0 (3) NM; * mometasone furoate cream 0.1% $0 (1) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not 100 available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) mometasone furoate oint 0.1% $0 (1) mometasone furoate solution 0.1% (lotion)$0 (1) prep h hc cre 1% $0 (3) sm hydrocort cre 1% $0 (3) texacort sol 2.5% $0-$6.60 (2) triamcinolone acetonide cream 0.1% $0 (1) triamcinolone acetonide cream 0.5% $0 (1) triamcinolone acetonide cream 0.025% $0 (1) triamcinolone acetonide lotion 0.1% $0 (1) triamcinolone acetonide lotion 0.025% $0 (1) triamcinolone acetonide oint 0.1% $0 (1) triamcinolone acetonide oint 0.5% $0 (1) triamcinolone acetonide oint 0.025% $0 (1) triderm cre 0.1% $0 (1) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE NM; * NM; * DERMATOLOGY, LOCAL ANESTHETICS dibucaine oint 1% dibucaine rectal ointment 1% lidocaine hcl gel 2% lidocaine hcl soln 4% lidocaine oint 5% lidocaine patch 5% $0 $0 $0 $0 $0 $0 (3) (3) (1) (1) (1) (1) lidocaine-prilocaine cream 2.5-2.5% lidocream cre 4% NUPERCAINAL OIN 1% $0 (1) $0 (3) $0 (3) NM; * NM; * QL (3 patches / 1 day), PA B/D NM; * NM; * DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ALOE VESTA LOT SKN COND baza protect cre BETADINE MIS SWAB AID BETADINE MIS SWABSTCK BETADINE SKN SOL 7.5% CLR BETASEPT LIQ 4% CALAMINE LOT capsaicin cream 0.025% ELIDEL CRE 1% fluorouracil cream 5% fluorouracil soln 2% fluorouracil soln 5% gnp vit a&d oin HEMORRHOIDAL OIN hemorrhoidal sup hm povid-iod sol 10% imiquimod cream 5% $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0 (3) $0-$6.60 (2) $0 (1) $0 (1) $0 (1) $0 (3) $0 (3) $0 (3) $0 (3) $0 (1) NM; NM; NM; NM; NM; NM; NM; NM; PA * * * * * * * * NM; NM; NM; NM; * * * * PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 101 Drug Name (By Medical Condition) WHAT THE DRUG WILL COST YOU (TIER LEVEL) laclotion lot 12% $0 (1) lactic acid (ammonium lactate) cream 12%$0 (1) lactic acid (ammonium lactate) lotion 12% $0 (1) metronidazole cream 0.75% $0 (1) metronidazole gel 0.75% $0 (1) metronidazole lotion 0.75% $0 (1) operand scrb sol 7.5% $0 (3) PANRETIN GEL 0.1% $0-$6.60 (2) pedi-boro pow soak pak $0 (3) periguard oin $0 (3) podofilox soln 0.5% $0 (1) povidone-iod sol 10% $0 (3) povidone-iodine oint 10% $0 (3) povidone-iodine soln 10% $0 (3) povidone-iodine swabs 10% $0 (3) PROSHIELD CRE PLUS $0 (3) PROSHIELD CRE PROTECT $0 (3) rosadan cre 0.75% $0 (1) SM CALAMINE LOT $0 (3) sm povid-iod sol 10% $0 (3) surgilube gel $0 (3) TARGRETIN GEL 1% $0-$6.60 (2) TRIXAICIN CRE 0.025% $0 (3) trixaicin hp cre 0.075% $0 (3) VALCHLOR GEL 0.016% $0-$6.60 (2) vitamins a & d oint $0 (3) VOLTAREN GEL 1% $0-$6.60 (2) zinc oxide oin 20% $0 (3) zinc oxide oint 20% $0 (3) NECESSARY ACTIONS RESTRICTIONS OR LIMITS ON USE NM; * NM; * NM; * NM; NM; NM; NM; NM; NM; * * * * * * NM; * NM; * NM; * NM, PA NM; * NM; * NM, LA, PA NM; * NM; * NM; * DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX CRE 10% EURAX LOT 10% lice treatmt sha 0.33-4% malathion lotion 0.5% permethrin cream 5% permethrin lotion 1% $0-$6.60 (2) $0-$6.60 (2) $0 (3) $0 (1) $0 (1) $0 (3) NM; * NM; * DERMATOLOGY, WOUND CARE AGENTS acetic acid irrigation soln 0.25% REGRANEX GEL 0.01% SANTYL OIN 250/GM SEA-CLENS LIQ WOUND SODIUM CHLORIDE IRRIGATION SOLN 0.9% $0 (1) $0-$6.60 (2) $0-$6.60 (2) $0 (3) $0 (1) PA NM; * PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 102 Drug Name (By Medical Condition) WATER FOR IRRIGATION, STERILE IRRIGATION SOLN WHAT THE NECESSARY ACTIONS DRUG WILL RESTRICTIONS OR COST YOU LIMITS ON USE (TIER LEVEL) $0 (1) MOUTH/THROAT/DENTAL AGENTS cevimeline hcl cap 30 mg $0 chlorhexidine gluconate soln 0.12% $0 clotrimazole troche 10 mg $0 lidocaine hcl viscous soln 2% $0 nystatin susp 100000 unit/ml $0 periogard sol 0.12% $0 pilocarpine hcl tab 5 mg $0 pilocarpine hcl tab 7.5 mg $0 triamcinolone acetonide dental paste 0.1% $0 (1) (1) (1) (1) (1) (1) (1) (1) (1) OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR acetic acid 2% in aluminum acetate otic soln acetic acid otic soln 2% CIPRODEX SUS 0.3-0.1% ear wax remv dro 6.5% ot ear wax remv sol 6.5% ot earwax remv sol 6.5% ot earwax trmnt dro 6.5% ot fluocinolone acetonide (otic) oil 0.01% gnp ear dro 6.5% ot gnp ear sys sol 6.5% ot neomycin-polymyxin-hc otic soln 1% neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ofloxacin otic soln 0.3% $0 (1) $0 (1) $0-$6.60 (2) $0 (3) $0 (3) $0 (3) $0 (3) $0 (1) $0 (3) $0 (3) $0 (1) $0 (1) NM; NM; NM; NM; * * * * NM; * NM; * $0 (1) _PART B DIABETIC METERS AND TEST STRIPS TRUE METRIX KIT METER TRUE METRIX TES TRUERESULT KIT SYSTEM TRUETEST TES Tier Tier Tier Tier 0 0 0 0 NM NM NM NM PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid 103 Index 3 3 DAY VAGINL CRE 2% ......................78 8 8-MOP CAP 10MG .............................99 A abacavir sulfate tab 300 mg (base equiv) ....................................................... 8 abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg .........................10 ABELCET INJ 5MG/ML ......................... 7 ABILIFY DISC TAB 10MG....................49 ABILIFY DISC TAB 15MG....................49 ABILIFY INJ 9.75MG ..........................49 ABILIFY MAIN INJ 300MG ..................49 ABILIFY MAIN INJ 400MG ..................49 ABILIFY SOL 1MG/ML ........................49 ABILIFY TAB 10MG ............................49 ABILIFY TAB 15MG ............................49 ABILIFY TAB 20MG ............................49 ABILIFY TAB 2MG .............................49 ABILIFY TAB 30MG ............................49 ABILIFY TAB 5MG .............................49 acamprosate calcium tab delayed release 333 mg ...........................................57 acarbose tab 100 mg.........................59 acarbose tab 25 mg ..........................59 acarbose tab 50 mg ..........................59 acebutolol hcl cap 200 mg .................31 acebutolol hcl cap 400 mg .................31 acetaminophen w/ codeine soln 120-12 mg/5ml ............................................ 2 acetaminophen w/ codeine tab 300-15 mg ....................................................... 2 acetaminophen w/ codeine tab 300-30 mg ....................................................... 2 acetaminophen w/ codeine tab 300-60 mg ....................................................... 2 acetazolamide cap sr 12hr 500 mg ......35 acetazolamide tab 125 mg .................35 acetazolamide tab 250 mg .................35 acetic acid 2% in aluminum acetate otic soln............................................... 103 acetic acid irrigation soln 0.25% ....... 102 acetic acid otic soln 2% ................... 103 acetylcysteine inhal soln 10% .............94 acetylcysteine inhal soln 20% .............94 acid gone sus ...................................70 acid reducer tab 10mg ...................... 72 acid reducer tab 75mg ...................... 72 acitretin cap 10 mg .......................... 98 acitretin cap 17.5 mg........................ 98 acitretin cap 25 mg .......................... 98 ACTHIB INJ ..................................... 85 ACTIMMUNE INJ 2MU/0.5 .................. 83 acyclovir cap 200 mg ........................ 11 acyclovir oint 5% ............................. 99 acyclovir sodium for inj 1000 mg ....... 11 acyclovir sodium for inj 500 mg ......... 11 acyclovir sodium iv soln 50 mg/ml...... 11 acyclovir susp 200 mg/5ml ................ 11 acyclovir tab 400 mg ........................ 11 acyclovir tab 800 mg ........................ 11 ADACEL INJ ..................................... 85 ADAGEN INJ 250/ML ......................... 64 adapalene cream 0.1% ..................... 96 adapalene gel 0.1% .......................... 96 ADCIRCA TAB 20MG ......................... 37 adefovir dipivoxil tab 10 mg .............. 11 ADEMPAS TAB 0.5MG ....................... 37 ADEMPAS TAB 1.5MG ....................... 37 ADEMPAS TAB 1MG .......................... 37 ADEMPAS TAB 2.5MG ....................... 37 ADEMPAS TAB 2MG .......................... 37 adriamyc inj 50mg ........................... 18 adrucil inj 500/10ml ......................... 19 ADVAIR DISKU AER 100/50 ............... 96 ADVAIR DISKU AER 250/50 ............... 96 ADVAIR DISKU AER 500/50 ............... 96 ADVAIR HFA AER 115/21 .................. 96 ADVAIR HFA AER 230/21 .................. 96 ADVAIR HFA AER 45/21 .................... 96 afeditab tab 30mg cr ........................ 32 afeditab tab 60mg cr ........................ 32 AFINITOR DIS TAB 2MG .................... 21 AFINITOR DIS TAB 3MG .................... 21 AFINITOR DIS TAB 5MG .................... 21 AFINITOR TAB 10MG ........................ 21 AFINITOR TAB 2.5MG ....................... 21 AFINITOR TAB 5MG .......................... 21 AFINITOR TAB 7.5MG ....................... 21 AGGRENOX CAP 25-200MG ............... 81 a-hydrocort inj 100mg ...................... 65 akwa tears oin op ............................. 92 ala cort cre 1% ................................ 99 104 ALBENZA TAB 200MG ......................... 6 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) ..........................................94 albuterol sulfate soln nebu 0.5% (5 mg/ml) ............................................94 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) .....................................94 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) .....................................94 albuterol sulfate syrup 2 mg/5ml ........94 albuterol sulfate tab 2 mg ..................94 albuterol sulfate tab 4 mg ..................94 albuterol sulfate tab sr 12hr 4 mg .......94 albuterol sulfate tab sr 12hr 8 mg .......94 alclometasone dipropionate cream 0.05% ......................................................99 alclometasone dipropionate oint 0.05% ......................................................99 ALCOHOL SWABS .............................59 ALDURAZYME INJ 2.9MG/5M ..............64 alendronate sodium tab 10 mg ...........60 alendronate sodium tab 35 mg ...........60 alendronate sodium tab 40 mg ...........61 alendronate sodium tab 5 mg .............60 alendronate sodium tab 70 mg ...........61 alfuzosin hcl tab sr 24hr 10 mg...........77 ALIMTA INJ 100MG ...........................19 ALIMTA INJ 500MG ...........................19 ALINIA SUS 100/5ML ......................... 6 ALINIA TAB 500MG ............................ 6 allopurinol tab 100 mg........................ 1 allopurinol tab 300 mg........................ 1 almacone dbl sus strength .................70 almacone sus ...................................70 ALOE VESTA LOT SKN COND ............ 101 alosetron hcl tab 0.5 mg (base equiv) .76 alosetron hcl tab 1 mg (base equiv) ....76 ALPHAGAN P SOL 0.1% .....................91 alprazolam con 1 mg/ml ....................38 alprazolam tab 0.25 mg .....................38 alprazolam tab 0.5 mg.......................38 alprazolam tab 1 mg .........................38 alprazolam tab 2 mg .........................38 ALREX SUS 0.2% ..............................90 altavera tab .....................................61 ALUM HYDROX SUS 320/5ML .............70 amantadine hcl cap 100 mg ...............47 amantadine hcl syrup 50 mg/5ml ........47 amantadine hcl tab 100 mg ............... 47 AMBISOME INJ 50MG.......................... 7 amcinonide cream 0.1% ................... 99 amcinonide lotion 0.1% .................... 99 amcinonide oin 0.1% ........................ 99 amifostine crystalline for inj 500 mg ... 23 amikacin sulfate inj 1 gm/4ml (250 mg/ml) ............................................. 5 amikacin sulfate inj 500 mg/2ml (250 mg/ml) ............................................. 5 amiloride & hydrochlorothiazide tab 5-50 mg ................................................. 35 amiloride hcl tab 5 mg ...................... 35 amino acid infusion 6% ..................... 87 aminophylline inj 25 mg/ml ............... 96 AMINOSYN 7% INJ /LYTES ................ 87 AMINOSYN II INJ 10% ...................... 87 AMINOSYN II INJ 7% ........................ 87 AMINOSYN II INJ 8.5% ..................... 87 AMINOSYN II INJ 8.5/LYTE ................ 87 AMINOSYN INJ 10% ......................... 87 AMINOSYN INJ 8.5% ........................ 87 AMINOSYN INJ 8.5/LYTE ................... 87 AMINOSYN M INJ 3.5% ..................... 87 AMINOSYN-HBC INJ 7% .................... 87 AMINOSYN-PF INJ 10% ..................... 87 AMINOSYN-PF INJ 7% ...................... 87 AMINOSYN-RF INJ 5.2% ................... 87 amiodarone hcl inj 150 mg/3ml (50 mg/ml) ........................................... 28 amiodarone hcl inj 450 mg/9ml (50 mg/ml) ........................................... 28 amiodarone hcl inj 900 mg/18ml (50 mg/ml) ........................................... 28 amiodarone hcl tab 100 mg ............... 28 amiodarone hcl tab 200 mg ............... 28 amiodarone hcl tab 400 mg ............... 28 AMITIZA CAP 24MCG ........................ 76 AMITIZA CAP 8MCG .......................... 76 amitriptyline hcl tab 10 mg ................ 44 amitriptyline hcl tab 100 mg .............. 44 amitriptyline hcl tab 150 mg .............. 44 amitriptyline hcl tab 25 mg ................ 44 amitriptyline hcl tab 50 mg ................ 44 amitriptyline hcl tab 75 mg ................ 44 amlodipine besylate tab 10 mg .......... 32 amlodipine besylate tab 2.5 mg ......... 32 amlodipine besylate tab 5 mg ............ 32 105 amlodipine besylate-benazepril hcl cap 10-20 mg ........................................24 amlodipine besylate-benazepril hcl cap 10-40 mg ........................................24 amlodipine besylate-benazepril hcl cap 2.5-10 mg .......................................24 amlodipine besylate-benazepril hcl cap 5-10 mg ..........................................24 amlodipine besylate-benazepril hcl cap 5-20 mg ..........................................24 amlodipine besylate-benazepril hcl cap 5-40 mg ..........................................24 amlodipine besylate-valsartan tab 10-160 mg ..................................................27 amlodipine besylate-valsartan tab 10-320 mg ..................................................27 amlodipine besylate-valsartan tab 5-160 mg ..................................................27 amlodipine besylate-valsartan tab 5-320 mg ..................................................27 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg ..........................27 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg ............................27 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg ............................27 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg ...........................27 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg ..............................27 amnesteem cap 10mg .......................96 amnesteem cap 20mg .......................96 amnesteem cap 40mg .......................96 amoxapine tab 100 mg ......................44 amoxapine tab 150 mg ......................44 amoxapine tab 25 mg........................44 amoxapine tab 50 mg........................44 amoxicillin & k clavulanate chew tab 200-28.5 mg ....................................15 amoxicillin & k clavulanate chew tab 400-57 mg .......................................15 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml .............................15 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml .............................15 amoxicillin & k clavulanate for susp 400-57 mg/5ml ................................15 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml ............................. 15 amoxicillin & k clavulanate tab 250-125 mg ................................................. 15 amoxicillin & k clavulanate tab 500-125 mg ................................................. 15 amoxicillin & k clavulanate tab 875-125 mg ................................................. 16 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg ................................. 16 amoxicillin (trihydrate) cap 250 mg .... 16 amoxicillin (trihydrate) cap 500 mg .... 16 amoxicillin (trihydrate) chew tab 125 mg ...................................................... 16 amoxicillin (trihydrate) chew tab 250 mg ...................................................... 16 amoxicillin (trihydrate) for susp 125 mg/5ml ........................................... 16 amoxicillin (trihydrate) for susp 200 mg/5ml ........................................... 16 amoxicillin (trihydrate) for susp 250 mg/5ml ........................................... 16 amoxicillin (trihydrate) for susp 400 mg/5ml ........................................... 16 amoxicillin (trihydrate) tab 500 mg .... 16 amoxicillin (trihydrate) tab 875 mg .... 16 amphetamine-dextroamphetamine cap sr 24hr 10 mg ..................................... 53 amphetamine-dextroamphetamine cap sr 24hr 15 mg ..................................... 54 amphetamine-dextroamphetamine cap sr 24hr 20 mg ..................................... 54 amphetamine-dextroamphetamine cap sr 24hr 25 mg ..................................... 54 amphetamine-dextroamphetamine cap sr 24hr 30 mg ..................................... 54 amphetamine-dextroamphetamine cap sr 24hr 5 mg ....................................... 53 amphetamine-dextroamphetamine tab 10 mg ................................................. 54 amphetamine-dextroamphetamine tab 12.5 mg .......................................... 54 amphetamine-dextroamphetamine tab 15 mg ................................................. 54 amphetamine-dextroamphetamine tab 20 mg ................................................. 54 amphetamine-dextroamphetamine tab 30 mg ................................................. 54 amphetamine-dextroamphetamine tab 5 106 mg ..................................................54 amphetamine-dextroamphetamine tab 7.5 mg ............................................54 amphotericin b for inj 50 mg ............... 7 ampicillin & sulbactam sodium for inj 1-0.5 gm .........................................16 ampicillin & sulbactam sodium for inj 10-5 gm ..................................................16 ampicillin & sulbactam sodium for inj 2-1 gm ..................................................16 ampicillin & sulbactam sodium for iv soln 1-0.5 gm .........................................16 ampicillin & sulbactam sodium for iv soln 10-5 gm ..........................................16 ampicillin & sulbactam sodium for iv soln 2-1 gm ............................................16 ampicillin cap 250 mg........................16 ampicillin cap 500 mg........................16 ampicillin for susp 125 mg/5ml ...........16 ampicillin for susp 250 mg/5ml ...........16 ampicillin sodium for inj 1 gm .............16 ampicillin sodium for inj 125 mg .........16 ampicillin sodium for inj 2 gm .............16 ampicillin sodium for inj 250 mg .........16 ampicillin sodium for inj 500 mg .........16 ampicillin sodium for iv soln 1 gm .......16 ampicillin sodium for iv soln 10 gm .....16 ampicillin sodium for iv soln 2 gm .......16 anagrelide hcl cap 0.5 mg ..................81 anagrelide hcl cap 1 mg .....................81 anastrozole tab 1 mg ........................20 ANDRODERM DIS 2MG/24HR..............58 ANDRODERM DIS 4MG/24HR..............58 ANORO ELLIPT AER 62.5-25 ...............93 antacid chw 1000mg .........................70 antacid chw 500mg ...........................70 antacid chw 750mg ...........................70 antacid fast sus acting .......................70 antacid plus sus gas rel .....................70 antacid sus ......................................70 antacid sus max st ............................70 antacid sus reg st .............................70 antibiotic cre plus .............................97 anti-diarrhe tab 2mg .........................71 antifungal cre 2% .............................98 APOKYN INJ 10MG/ML .......................48 apri tab ...........................................61 APRISO CAP 0.375GM .......................73 APTIOM TAB 200MG ......................... 38 APTIOM TAB 400MG ......................... 38 APTIOM TAB 600MG ......................... 38 APTIOM TAB 800MG ......................... 38 APTIVUS CAP 250MG .......................... 8 APTIVUS SOL ..................................... 8 ARALAST NP INJ 1000MG .................. 94 ARALAST NP INJ 400MG .................... 94 ARALAST NP INJ 500MG .................... 94 ARALAST NP INJ 800MG .................... 94 aranelle tab ..................................... 61 ARCALYST INJ 220MG ....................... 83 aripiprazole oral solution 1 mg/ml ...... 49 aripiprazole tab 10 mg ...................... 49 aripiprazole tab 15 mg ...................... 49 aripiprazole tab 2 mg ........................ 49 aripiprazole tab 20 mg ...................... 49 aripiprazole tab 30 mg ...................... 49 aripiprazole tab 5 mg ........................ 49 artifi tears oin op ............................. 92 artifi tears sol 1.4% op ..................... 92 artifi tears sol op .............................. 92 artificial sol tears.............................. 92 ASACOL HD TAB 800MG .................... 73 ASMANEX 120 AER 220MCG .............. 95 ASMANEX 14 AER 220MCG ................ 95 ASMANEX 30 AER 110MCG ................ 95 ASMANEX 30 AER 220MCG ................ 95 ASMANEX 60 AER 220MCG ................ 95 ASPIRIN-DIPYRIDAMOLE CAP SR 12HR 25-200 MG ...................................... 81 ASTEPRO SPR 0.15% ........................ 93 atenolol & chlorthalidone tab 100-25 mg ...................................................... 30 atenolol & chlorthalidone tab 50-25 mg ...................................................... 30 atenolol tab 100 mg ......................... 31 atenolol tab 25 mg ........................... 31 atenolol tab 50 mg ........................... 31 athlete foot cre 1% .......................... 98 atorvastatin calcium tab 10 mg (base equivalent) ...................................... 29 atorvastatin calcium tab 20 mg (base equivalent) ...................................... 29 atorvastatin calcium tab 40 mg (base equivalent) ...................................... 29 atorvastatin calcium tab 80 mg (base equivalent) ...................................... 29 107 atovaquone susp 750 mg/5ml ............. 6 atovaquone-proguanil hcl tab 250-100 mg ....................................................... 8 atovaquone-proguanil hcl tab 62.5-25 mg ....................................................... 8 ATRIPLA TAB ....................................10 ATROVENT HFA AER 17MCG ...............93 aubra tab 0.1-0.02 ............................61 AUVI-Q INJ 0.15MG ..........................95 AUVI-Q INJ 0.3MG ............................95 AVASTIN INJ ....................................20 AVASTIN INJ 400/16ML .....................20 aviane tab........................................61 AVITA CRE 0.025% ...........................96 AVITA GEL 0.025% ...........................96 AVODART CAP 0.5MG ........................77 AYR NASAL DRO 0.65% .....................95 ayr spr 0.65% ..................................95 azacitidine for inj 100 mg ..................19 AZACTAM INJ 1GM ............................. 6 AZACTAM INJ 2GM ............................. 6 AZACTAM/DEX INJ 1GM ...................... 6 AZACTAM/DEX INJ 2GM ...................... 6 azathioprine tab 50 mg ......................84 azelastine hcl nasal spray 0.1% (137 mcg/spray) ......................................93 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) ......................................93 azelastine hcl ophth soln 0.05% .........91 AZILECT TAB 0.5MG ..........................48 AZILECT TAB 1MG.............................48 azithromycin for susp 100 mg/5ml ......14 azithromycin for susp 200 mg/5ml ......14 azithromycin iv for soln 500 mg ..........14 AZITHROMYCIN POWD PACK FOR SUSP 1 GM ..................................................14 azithromycin tab 250 mg ...................14 azithromycin tab 500 mg ...................14 azithromycin tab 600 mg ...................14 AZOPT SUS 1% OP ...........................91 AZOR TAB 10-20MG ..........................27 AZOR TAB 10-40MG ..........................27 AZOR TAB 5-20MG ............................27 AZOR TAB 5-40MG ............................27 aztreonam for inj 1 gm ....................... 6 aztreonam for inj 2 gm ....................... 6 B bacitr zinc oin 500/gm .......................97 bacitracin oin 500/gm ....................... 97 bacitracin oint 500 unit/gm ............... 97 bacitracin ophth oint 500 unit/gm ...... 90 bacitracin zinc oint 500 unit/gm ......... 97 bacitracin-polymyxin b ophth oint ...... 90 bacitracin-polymyxin-neomycin-hc ophth oint 1% .......................................... 89 baclofen tab 10 mg .......................... 56 baclofen tab 20 mg .......................... 56 balsalazide disodium cap 750 mg ....... 73 balziva tab ...................................... 61 BANZEL SUS 40MG/ML ..................... 38 BANZEL TAB 200MG ......................... 38 BANZEL TAB 400MG ......................... 38 BARACLUDE SOL .05MG/ML ............... 11 baza antifun cre 2% ......................... 98 baza protect cre ............................. 101 BCG VACCINE INJ ............................ 85 benazepril & hydrochlorothiazide tab 10-12.5 mg ..................................... 24 benazepril & hydrochlorothiazide tab 20-12.5 mg ..................................... 24 benazepril & hydrochlorothiazide tab 20-25 mg ........................................ 24 benazepril & hydrochlorothiazide tab 5-6.25 mg ....................................... 24 benazepril hcl tab 10 mg ................... 25 benazepril hcl tab 20 mg ................... 25 benazepril hcl tab 40 mg ................... 25 benazepril hcl tab 5 mg..................... 25 BENICAR HCT TAB 20-12.5................ 27 BENICAR HCT TAB 40-12.5................ 27 BENICAR HCT TAB 40-25MG .............. 27 BENICAR TAB 20MG ......................... 28 BENICAR TAB 40MG ......................... 28 BENICAR TAB 5MG ........................... 28 benzoyl peroxide-erythromycin gel 5-3% ...................................................... 96 benztropine mesylate inj 1 mg/ml ...... 48 benztropine mesylate tab 0.5 mg ....... 48 benztropine mesylate tab 1 mg .......... 48 benztropine mesylate tab 2 mg .......... 48 BEPREVE DRO 1.5% ......................... 91 BESIVANCE SUS 0.6% ...................... 90 BETADINE MIS SWAB AID ............... 101 BETADINE MIS SWABSTCK .............. 101 BETADINE SKN SOL 7.5% CLR ......... 101 betamethasone dipropionate augmented 108 cream 0.05% ...................................99 betamethasone dipropionate augmented gel 0.05% ........................................99 betamethasone dipropionate augmented lotion 0.05% ....................................99 betamethasone dipropionate augmented oint 0.05% .......................................99 betamethasone dipropionate cream 0.05% .............................................99 betamethasone dipropionate lotion 0.05% ......................................................99 betamethasone dipropionate oint 0.05% ......................................................99 betamethasone valerate cream 0.1% ..99 betamethasone valerate lotion 0.1% ...99 betamethasone valerate oint 0.1%......99 BETASEPT LIQ 4% .......................... 101 BETASERON INJ 0.3MG......................56 betaxolol hcl ophth soln 0.5% ............91 bethanechol chloride tab 10 mg ..........78 bethanechol chloride tab 25 mg ..........78 bethanechol chloride tab 5 mg ............78 bethanechol chloride tab 50 mg ..........78 BETOPTIC-S SUS 0.25% OP ...............91 bexarotene cap 75 mg .......................23 BEXSERO INJ ...................................85 bicalutamide tab 50 mg .....................20 BICILLIN L-A INJ 1200000 .................16 BICILLIN L-A INJ 2400000 .................16 BICILLIN L-A INJ 600000 ...................16 BICNU INJ 100MG .............................18 BILTRICIDE TAB 600MG ..................... 6 bisac-evac sup 10mg .........................73 bisacodyl suppos 10 mg .....................73 bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit .......................73 bisacodyl tab 5mg ec .........................73 biscolax sup 10mg ............................73 bismatrol chw 262mg ........................71 bismatrol sus 262/15ml .....................71 bismatrol sus 525/15ml .....................71 bisoprolol & hydrochlorothiazide tab 10-6.25 mg ......................................31 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg .....................................31 bisoprolol & hydrochlorothiazide tab 5-6.25 mg .......................................31 bisoprolol fumarate tab 10 mg ............31 bisoprolol fumarate tab 5 mg ............. 31 BIVIGAM INJ 10% ............................ 82 bleomycin sulfate for inj 15 unit ......... 19 bleomycin sulfate for inj 30 unit ......... 19 blephamide oin s.o.p. ....................... 89 BOOSTRIX INJ ................................. 85 BOSULIF TAB 100MG ........................ 21 BOSULIF TAB 500MG ........................ 21 BREO ELLIPTA INH 100-25 ................ 96 BREO ELLIPTA INH 200-25 ................ 96 briellyn tab ...................................... 61 BRILINTA TAB 60MG ......................... 82 BRILINTA TAB 90MG ......................... 82 BRIMONIDINE TARTRATE OPHTH SOLN 0.15% ............................................ 91 brimonidine tartrate ophth soln 0.2% . 91 BRINTELLIX TAB 10MG ..................... 44 BRINTELLIX TAB 20MG ..................... 44 BRINTELLIX TAB 5MG ....................... 44 BROMFENAC SODIUM OPHTH SOLN 0.09% (BASE EQUIV) (ONCE-DAILY) .. 90 bromfenac sodium ophth soln 0.09% (base equivalent) ............................. 90 bromocriptine mesylate cap 5 mg....... 48 bromocriptine mesylate tab 2.5 mg .... 48 budesonide cap sr 24hr 3 mg............. 73 budesonide inhalation susp 0.25 mg/2ml ...................................................... 95 budesonide inhalation susp 0.5 mg/2ml ...................................................... 95 bumetanide inj 0.25 mg/ml ............... 35 bumetanide tab 0.5 mg ..................... 35 bumetanide tab 1 mg ....................... 35 bumetanide tab 2 mg ....................... 35 buprenorphine hcl sl tab 2 mg (base equiv) ............................................. 57 buprenorphine hcl sl tab 8 mg (base equiv) ............................................. 57 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) ...................... 57 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)............................... 57 buproban tab 150mg ........................ 57 bupropion hcl tab 100 mg ................. 44 bupropion hcl tab 75 mg ................... 44 bupropion hcl tab sr 12hr 100 mg ...... 44 bupropion hcl tab sr 12hr 150 mg ...... 44 bupropion hcl tab sr 12hr 200 mg ...... 44 109 bupropion hcl tab sr 24hr 150 mg .......44 bupropion hcl tab sr 24hr 300 mg .......44 buspirone hcl tab 10 mg ....................38 buspirone hcl tab 15 mg ....................38 buspirone hcl tab 30 mg ....................38 buspirone hcl tab 5 mg ......................38 buspirone hcl tab 7.5 mg ...................38 BUSULFEX INJ 6MG/ML ......................18 butorphanol tartrate inj 1 mg/ml ......... 2 butorphanol tartrate inj 2 mg/ml ......... 2 BYSTOLIC TAB 10MG .........................31 BYSTOLIC TAB 2.5MG ........................31 BYSTOLIC TAB 20MG .........................31 BYSTOLIC TAB 5MG ..........................31 C cabergoline tab 0.5 mg ......................67 cafergot tab 1-100mg........................55 CALAMINE LOT ............................... 101 calc antacid chw 500mg .....................70 calc antacid chw 750mg .....................70 calcipotriene cream 0.005% ...............98 calcipotriene oint 0.005% ..................99 calcipotriene soln 0.005% (50 mcg/ml) ......................................................99 calcitonin (salmon) nasal soln 200 unit/act ......................................................67 calcitrene oin 0.005%........................99 calcitriol cap 0.25 mcg .......................89 calcitriol cap 0.5 mcg ........................89 calcitriol inj 1 mcg/ml ........................89 calcitriol oral soln 1 mcg/ml ...............89 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) .........................68 calcium polycarbophil tab 625 mg .......73 cal-gest chw 500mg ..........................70 camila tab 0.35mg ............................61 CANASA SUP 1000MG .......................73 CANCIDAS INJ 50MG .......................... 7 CANCIDAS INJ 70MG .......................... 7 CAPASTAT SUL INJ 1GM ....................11 CAPRELSA TAB 100MG ......................21 CAPRELSA TAB 300MG ......................21 capsaicin cream 0.025% .................. 101 captopril & hydrochlorothiazide tab 25-15 mg ..................................................24 captopril & hydrochlorothiazide tab 25-25 mg ..................................................24 captopril & hydrochlorothiazide tab 50-15 mg ................................................. 25 captopril & hydrochlorothiazide tab 50-25 mg ................................................. 25 captopril tab 100 mg ........................ 25 captopril tab 12.5 mg ....................... 25 captopril tab 25 mg .......................... 25 captopril tab 50 mg .......................... 25 CARBAGLU TAB 200MG ..................... 64 carbamazepine cap sr 12hr 100 mg .... 38 carbamazepine cap sr 12hr 200 mg .... 38 carbamazepine cap sr 12hr 300 mg .... 38 carbamazepine chew tab 100 mg ....... 38 carbamazepine susp 100 mg/5ml ....... 38 carbamazepine tab 200 mg ............... 38 carbamazepine tab sr 12hr 200 mg .... 38 carbamazepine tab sr 12hr 400 mg .... 38 carbidopa & levodopa orally disintegrating tab 10-100 mg................................. 48 carbidopa & levodopa orally disintegrating tab 25-100 mg................................. 48 carbidopa & levodopa orally disintegrating tab 25-250 mg................................. 48 carbidopa & levodopa tab 10-100 mg . 48 carbidopa & levodopa tab 25-100 mg . 48 carbidopa & levodopa tab 25-250 mg . 48 carbidopa & levodopa tab cr 25-100 mg ...................................................... 48 carbidopa & levodopa tab cr 50-200 mg ...................................................... 48 CARBIDOPA-LEVODOPA-ENTACAPONE TABS 12.5-50-200 MG ...................... 48 CARBIDOPA-LEVODOPA-ENTACAPONE TABS 18.75-75-200 MG .................... 48 CARBIDOPA-LEVODOPA-ENTACAPONE TABS 25-100-200 MG ....................... 48 CARBIDOPA-LEVODOPA-ENTACAPONE TABS 31.25-125-200 MG .................. 48 CARBIDOPA-LEVODOPA-ENTACAPONE TABS 37.5-150-200 MG .................... 48 CARBIDOPA-LEVODOPA-ENTACAPONE TABS 50-200-200 MG ....................... 48 carboplatin iv soln 150 mg/15ml ........ 23 carboplatin iv soln 450 mg/45ml ........ 23 carboplatin iv soln 50 mg/5ml ............ 23 carboplatin iv soln 600 mg/60ml ........ 23 CARIMUNE NF INJ 12GM ................... 82 CARIMUNE NF INJ 3GM ..................... 82 CARIMUNE NF INJ 6GM ..................... 82 110 carteolol hcl ophth soln 1% ................91 carvedilol tab 12.5 mg .......................31 carvedilol tab 25 mg .........................31 carvedilol tab 3.125 mg .....................31 carvedilol tab 6.25 mg .......................31 CAYSTON INH 75MG .......................... 6 cefaclor cap 250 mg ..........................12 cefaclor cap 500 mg ..........................12 cefaclor er tab 500mg .......................12 cefaclor for susp 125 mg/5ml .............12 cefaclor for susp 250 mg/5ml .............12 cefaclor for susp 375 mg/5ml .............12 cefadroxil cap 500 mg .......................12 cefadroxil for susp 250 mg/5ml ..........12 cefadroxil for susp 500 mg/5ml ..........12 cefadroxil tab 1 gm ...........................12 cefazolin inj 1gm/50ml ......................12 cefazolin sodium for inj 1 gm..............12 cefazolin sodium for inj 10 gm ............12 cefazolin sodium for inj 20 gm ............12 cefazolin sodium for inj 500 mg ..........12 cefazolin sodium for iv soln 1 gm ........13 cefdinir cap 300 mg ..........................13 cefdinir for susp 125 mg/5ml..............13 cefdinir for susp 250 mg/5ml..............13 cefepime hcl for inj 1 gm ...................13 cefepime hcl for inj 2 gm ...................13 cefixime for susp 100 mg/5ml ............13 cefixime for susp 200 mg/5ml ............13 cefotaxime sodium for inj 1 gm ..........13 cefotaxime sodium for inj 2 gm ..........13 cefotaxime sodium for inj 500 mg .......13 cefoxitin sodium for inj 10 gm ............13 cefoxitin sodium for iv soln 1 gm ........13 cefoxitin sodium for iv soln 2 gm ........13 cefpodoxime proxetil for susp 100 mg/5ml ......................................................13 cefpodoxime proxetil for susp 50 mg/5ml ......................................................13 cefpodoxime proxetil tab 100 mg ........13 cefpodoxime proxetil tab 200 mg ........13 cefprozil for susp 125 mg/5ml ............13 cefprozil for susp 250 mg/5ml ............13 cefprozil tab 250 mg .........................13 cefprozil tab 500 mg .........................13 ceftazidime for inj 1 gm .....................13 ceftazidime for inj 2 gm .....................13 ceftazidime for inj 6 gm .....................13 CEFTAZIDIME/ SOL D5W 1GM ........... 13 CEFTAZIDIME/ SOL D5W 2GM ........... 13 ceftriaxone sodium for inj 1 gm ......... 13 ceftriaxone sodium for inj 10 gm ........ 13 ceftriaxone sodium for inj 2 gm ......... 13 ceftriaxone sodium for inj 250 mg ...... 13 ceftriaxone sodium for inj 500 mg ...... 13 ceftriaxone sodium for iv soln 1 gm .... 13 ceftriaxone sodium for iv soln 2 gm .... 13 cefuroxime axetil tab 250 mg ............ 13 cefuroxime axetil tab 500 mg ............ 13 cefuroxime inj 7.5gm ........................ 13 cefuroxime sodium for inj 1.5 gm ....... 13 cefuroxime sodium for inj 7.5 gm ....... 13 cefuroxime sodium for inj 750 mg ...... 13 cefuroxime sodium for iv soln 1.5 gm . 13 celecoxib cap 100 mg ......................... 1 celecoxib cap 200 mg ......................... 1 celecoxib cap 400 mg ......................... 1 celecoxib cap 50 mg ........................... 1 CELONTIN CAP 300MG ...................... 38 cephalexin cap 250 mg ..................... 13 cephalexin cap 500 mg ..................... 14 cephalexin for susp 125 mg/5ml ........ 14 cephalexin for susp 250 mg/5ml ........ 14 CERDELGA CAP 84MG ....................... 64 CEREZYME INJ 200UNIT .................... 64 CEREZYME INJ 400UNIT .................... 64 CERVARIX INJ .................................. 85 cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) ......................................... 93 cevimeline hcl cap 30 mg ................ 103 CHANTIX PAK 0.5& 1MG ................... 57 CHANTIX PAK 1MG ........................... 57 CHANTIX TAB 0.5MG ........................ 57 CHANTIX TAB 1MG ........................... 57 CHEMET CAP 100MG ......................... 61 chlorhexidine gluconate soln 0.12%.. 103 chloroquine phosphate tab 250 mg ....... 8 chloroquine phosphate tab 500 mg ....... 8 chlorothiazide tab 250 mg ................. 35 chlorothiazide tab 500 mg ................. 35 chlorpromaz inj 50mg/2ml ................ 49 chlorpromazine hcl tab 10 mg ............ 49 chlorpromazine hcl tab 100 mg .......... 50 chlorpromazine hcl tab 200 mg .......... 50 chlorpromazine hcl tab 25 mg ............ 50 chlorpromazine hcl tab 50 mg ............ 50 111 chlorthalidone tab 25 mg ...................35 chlorthalidone tab 50 mg ...................35 cholestyramine light powder packets 4 gm ......................................................30 cholestyramine powder 4 gm/dose ......30 cholestyramine powder packets 4 gm ..30 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) ........................30 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) ........................30 ciclopirox gel 0.77% ..........................98 ciclopirox olamine cream 0.77% (base equiv) .............................................98 ciclopirox olamine susp 0.77% (base equiv) .............................................98 ciclopirox shampoo 1% ......................98 cilostazol tab 100 mg ........................81 cilostazol tab 50 mg ..........................81 CILOXAN OIN 0.3% OP ......................90 CIMZIA KIT ......................................82 CIMZIA KIT STARTER ........................82 CIMZIA PREFL KIT 200MG/ML .............82 CINRYZE SOL 500 UNIT .....................81 CIPRODEX SUS 0.3-0.1% ................ 103 ciprofloxacin 200 mg/100ml in d5w .....15 ciprofloxacin 400 mg/200ml in d5w .....15 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) ..........................15 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) .......................15 ciprofloxacin hcl ophth soln 0.3% ........90 ciprofloxacin hcl tab 100 mg (base equiv) ......................................................15 ciprofloxacin hcl tab 250 mg (base equiv) ......................................................15 ciprofloxacin hcl tab 500 mg (base equiv) ......................................................15 ciprofloxacin hcl tab 750 mg (base equiv) ......................................................15 ciprofloxacin iv soln 200 mg/20ml (1%) ......................................................15 ciprofloxacin iv soln 400 mg/40ml (1%) ......................................................15 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) ............................15 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) .............................15 cisplatin inj 100 mg/100ml (1 mg/ml) .23 cisplatin inj 200 mg/200ml (1 mg/ml) . 23 cisplatin inj 50 mg/50ml (1 mg/ml) .... 23 citalopram hydrobromide oral soln 10 mg/5ml ........................................... 44 citalopram hydrobromide tab 10 mg (base equiv) ............................................. 44 citalopram hydrobromide tab 20 mg (base equiv) ............................................. 44 citalopram hydrobromide tab 40 mg (base equiv) ............................................. 44 CITRUCEL POW ORANGE ................... 73 CITRUCEL POW SF ORANG ................ 73 cladribine inj 1 mg/ml ....................... 19 claravis cap 10mg ............................ 96 claravis cap 20mg ............................ 96 claravis cap 30mg ............................ 96 claravis cap 40mg ............................ 96 clarithromycin for susp 125 mg/5ml ... 14 clarithromycin for susp 250 mg/5ml ... 14 clarithromycin tab 250 mg ................ 14 clarithromycin tab 500 mg ................ 14 clarithromycin tab sr 24hr 500 mg ..... 14 clindamax gel 1%............................. 97 clindamycin hcl cap 150 mg ................. 6 clindamycin hcl cap 300 mg ................. 6 clindamycin hcl cap 75 mg .................. 6 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) .......................... 6 clindamycin phosphate gel 1% ........... 97 clindamycin phosphate inj 300 mg/2ml . 6 clindamycin phosphate inj 600 mg/4ml . 6 clindamycin phosphate inj 9 gm/60ml ... 6 clindamycin phosphate inj 900 mg/6ml . 6 clindamycin phosphate iv soln 300 mg/2ml ............................................. 6 clindamycin phosphate iv soln 600 mg/4ml ............................................. 6 clindamycin phosphate iv soln 900 mg/6ml ............................................. 6 clindamycin phosphate lotion 1% ....... 97 clindamycin phosphate soln 1% ......... 97 clindamycin phosphate swab 1% ........ 97 clindamycin phosphate vaginal cream 2% ...................................................... 78 CLINIMIX INJ 2.75/D5W ................... 87 CLINIMIX INJ 4.25/D10 .................... 87 CLINIMIX INJ 4.25/D20 .................... 87 CLINIMIX INJ 4.25/D25 .................... 87 112 CLINIMIX INJ 4.25/D5W ....................87 CLINIMIX INJ 5%/D15W ....................87 CLINIMIX INJ 5%/D20W ....................87 CLINIMIX INJ 5%/D25W ....................87 clobetasol e cre 0.05% ......................99 clobetasol propionate cream 0.05% ....99 clobetasol propionate gel 0.05% .........99 clobetasol propionate oint 0.05% ........99 clobetasol propionate soln 0.05% .......99 clomipramine hcl cap 25 mg ...............44 clomipramine hcl cap 50 mg ...............45 clomipramine hcl cap 75 mg ...............45 clonazepam orally disintegrating tab 0.125 mg .........................................39 clonazepam orally disintegrating tab 0.25 mg ..................................................38 clonazepam orally disintegrating tab 0.5 mg ..................................................38 clonazepam orally disintegrating tab 1 mg ......................................................39 clonazepam orally disintegrating tab 2 mg ......................................................39 clonazepam tab 0.5 mg .....................39 clonazepam tab 1 mg ........................39 clonazepam tab 2 mg ........................39 clonidine hcl tab 0.1 mg.....................36 clonidine hcl tab 0.2 mg.....................36 clonidine hcl tab 0.3 mg.....................36 clonidine hcl td patch weekly 0.1 mg/24hr ......................................................36 clonidine hcl td patch weekly 0.2 mg/24hr ......................................................36 clonidine hcl td patch weekly 0.3 mg/24hr ......................................................36 clopidogrel bisulfate tab 75 mg (base equiv) .............................................82 clorazepate dipotassium tab 15 mg .....39 clorazepate dipotassium tab 3.75 mg ..39 clorazepate dipotassium tab 7.5 mg ....39 clotrimazole cre 1% ..........................98 clotrimazole cre 1% vag ....................78 clotrimazole cre 3 day .......................78 CLOTRIMAZOLE CRE 3 DAY ................78 clotrimazole cream 1% ......................98 clotrimazole soln 1% .........................98 clotrimazole troche 10 mg ................ 103 clotrimazole vaginal cream 1% ...........78 CLOZAPINE ORALLY DISINTEGRATING TAB 100 MG .................................... 50 CLOZAPINE ORALLY DISINTEGRATING TAB 12.5 MG ................................... 50 CLOZAPINE ORALLY DISINTEGRATING TAB 150 MG .................................... 50 CLOZAPINE ORALLY DISINTEGRATING TAB 200 MG .................................... 50 CLOZAPINE ORALLY DISINTEGRATING TAB 25 MG ...................................... 50 clozapine tab 100 mg ....................... 50 clozapine tab 200 mg ....................... 50 clozapine tab 25 mg ......................... 50 clozapine tab 50 mg ......................... 50 COARTEM TAB 20-120MG .................... 8 colchicine w/ probenecid tab 0.5-500 mg ........................................................ 1 COLCRYS TAB 0.6MG .......................... 1 colestipol hcl granule packets 5 gm .... 30 colestipol hcl granules 5 gm .............. 30 colestipol hcl tab 1 gm ...................... 30 colistimethate sodium for inj 150 mg .... 6 COMBIGAN SOL 0.2/0.5% ................. 91 COMBIPATCH DIS .05/.14 ................. 65 COMBIPATCH DIS .05/.25 ................. 65 COMBIVENT AER RESPIMAT ............... 93 COMETRIQ KIT 100MG ...................... 21 COMETRIQ KIT 140MG ...................... 21 COMETRIQ KIT 60MG ....................... 21 COMPLERA TAB ................................ 10 compro sup 25mg ............................ 71 COMVAX INJ .................................... 85 constulose sol 10gm/15 .................... 74 COPAXONE INJ 20MG/ML .................. 56 COPAXONE INJ 40MG/ML .................. 56 cormax scalp sol 0.05% .................... 99 cortisone acetate tab 25 mg .............. 65 COUMADIN TAB 10MG ...................... 79 COUMADIN TAB 1MG ........................ 79 COUMADIN TAB 2.5MG ..................... 79 COUMADIN TAB 2MG ........................ 79 COUMADIN TAB 3MG ........................ 79 COUMADIN TAB 4MG ........................ 79 COUMADIN TAB 5MG ........................ 79 COUMADIN TAB 6MG ........................ 79 COUMADIN TAB 7.5MG ..................... 79 CREON CAP 12000UNT...................... 76 CREON CAP 24000UNT...................... 77 CREON CAP 3000UNIT ...................... 76 113 CREON CAP 36000UNT ......................77 CREON CAP 6000UNIT .......................76 CRESTOR TAB 10MG .........................29 CRESTOR TAB 20MG .........................29 CRESTOR TAB 40MG .........................29 CRESTOR TAB 5MG ...........................29 critic-aid oin 2% ...............................98 CRIXIVAN CAP 200MG ........................ 8 CRIXIVAN CAP 400MG ........................ 8 cromolyn sodium ophth soln 4% .........91 cromolyn sodium oral conc 100 mg/5ml ......................................................76 cromolyn sodium soln nebu 20 mg/2ml ......................................................94 cryselle-28 tab 28 tabs ......................61 CUBICIN SOL 500MG.......................... 6 CUVPOSA SOL 1MG/5ML ....................72 cvs electrol sol..................................86 cvs fiber la tab 625mg .......................74 cvs iron tab 325mg ...........................81 cyclafem tab 1/35 .............................61 cyclafem tab 7/7/7 ............................61 cyclobenzaprine hcl tab 10 mg ...........57 cyclobenzaprine hcl tab 5 mg .............56 CYCLOPHOSPH CAP 25MG ..................18 CYCLOPHOSPH CAP 50MG ..................18 cyclophosphamide for inj 1 gm ...........18 cyclophosphamide for inj 2 gm ...........18 cyclophosphamide for inj 500 mg ........18 cycloserine cap 250 mg .....................11 cyclosporine cap 100 mg ...................84 cyclosporine cap 25 mg .....................84 cyclosporine iv soln 50 mg/ml ............84 cyclosporine modified cap 100 mg ......84 cyclosporine modified cap 25 mg ........84 cyclosporine modified cap 50 mg ........84 cyclosporine modified oral soln 100 mg/ml ......................................................84 CYSTADANE POW..............................64 CYSTAGON CAP 150MG .....................64 CYSTAGON CAP 50MG .......................64 cytarabine inj 20 mg/ml ....................19 D D10W/NACL INJ 0.2% .......................87 D5W/LYTES INJ #48 .........................87 D5W/NACL INJ 0.3% .........................87 dacarbazine for inj 100 mg ................18 dacarbazine for inj 200 mg ................18 DALIRESP TAB 500MCG .................... 95 danazol cap 100 mg ......................... 64 danazol cap 200 mg ......................... 64 danazol cap 50 mg ........................... 64 dantrolene sodium cap 100 mg .......... 57 dantrolene sodium cap 25 mg ............ 57 dantrolene sodium cap 50 mg ............ 57 dapsone tab 100 mg ........................... 6 dapsone tab 25 mg ............................ 6 DAPTACEL INJ ................................. 85 DARAPRIM TAB 25MG ......................... 6 daunorubicin hcl inj 5 mg/ml (base equiv) ...................................................... 18 deblitane tab 0.35mg........................ 61 deep sea spr 0.65% ......................... 95 delyla tab 0.1-0.02 ........................... 61 DELZICOL CAP 400MG ...................... 73 DEMSER CAP 250MG ........................ 36 DENAVIR CRE 1% ............................ 99 DEPEN TITRA TAB 250MG ................. 61 DEPO-PROVERA INJ 400/ML .............. 20 desenex aer 2% ............................... 98 desenex shak pow 2% ...................... 98 desipramine hcl tab 10 mg ................ 45 desipramine hcl tab 100 mg .............. 45 desipramine hcl tab 150 mg .............. 45 desipramine hcl tab 25 mg ................ 45 desipramine hcl tab 50 mg ................ 45 desipramine hcl tab 75 mg ................ 45 desmopressin acetate inj 4 mcg/ml .... 70 DESMOPRESSIN ACETATE NASAL SOLN 0.01% (REFRIGERATED) ................... 70 desmopressin acetate nasal spray soln 0.01% ............................................ 70 desmopressin acetate nasal spray soln 0.01% (refrigerated) ........................ 70 desmopressin acetate tab 0.1 mg ....... 70 desmopressin acetate tab 0.2 mg ....... 70 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5).................. 62 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg ..................................... 62 DESONIDE CREAM 0.05% ................. 99 desonide lotion 0.05% ...................... 99 desonide oint 0.05%......................... 99 desoximetasone cream 0.05% ......... 100 desoximetasone cream 0.25% ......... 100 desoximetasone gel 0.05%.............. 100 114 DESOXIMETASONE OINT 0.05% ....... 100 desoximetasone oint 0.25% ............. 100 dexamethason con 1mg/ml ................65 dexamethasone elixir 0.5 mg/5ml .......65 dexamethasone sod phosphate preservative free inj 10 mg/ml ...........65 dexamethasone sodium phosphate inj 10 mg/ml .............................................65 dexamethasone sodium phosphate inj 100 mg/10ml .........................................66 dexamethasone sodium phosphate inj 120 mg/30ml .........................................66 dexamethasone sodium phosphate inj 20 mg/5ml ...........................................65 dexamethasone sodium phosphate ophth soln 0.1% ........................................90 dexamethasone soln 0.5 mg/5ml ........66 dexamethasone tab 0.5 mg ................66 dexamethasone tab 0.75 mg ..............66 dexamethasone tab 1 mg ..................66 dexamethasone tab 1.5 mg ................66 dexamethasone tab 2 mg ..................66 dexamethasone tab 4 mg ..................66 dexamethasone tab 6 mg ..................66 DEXILANT CAP 30MG DR ...................77 DEXILANT CAP 60MG DR ...................77 dexrazoxane for inj 250 mg ...............23 DEXTROSE 10% W/ SODIUM CHLORIDE 0.45% .............................................88 DEXTROSE 2.5% W/ SODIUM CHLORIDE 0.45% .............................................88 DEXTROSE 5% IN LACTATED RINGERS88 DEXTROSE 5% W/ SODIUM CHLORIDE 0.2% ...............................................88 DEXTROSE 5% W/ SODIUM CHLORIDE 0.225% ...........................................88 DEXTROSE 5% W/ SODIUM CHLORIDE 0.33% .............................................88 DEXTROSE 5% W/ SODIUM CHLORIDE 0.45% .............................................88 DEXTROSE 5% W/ SODIUM CHLORIDE 0.9% ...............................................88 DEXTROSE INJ 10% ..........................88 DEXTROSE INJ 5% ............................88 DEXTROSE INJ 50% ..........................88 dextrose inj 70% ..............................88 diazepam con 5mg/ml .......................39 diazepam inj 5 mg/ml .......................39 DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG ................................ 39 DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG ............................... 39 DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG ................................ 39 diazepam soln 1 mg/ml ..................... 39 diazepam tab 10 mg ......................... 39 diazepam tab 2 mg........................... 39 diazepam tab 5 mg........................... 39 dibucaine oint 1% .......................... 101 dibucaine rectal ointment 1% .......... 101 diclofenac potassium tab 50 mg ........... 1 diclofenac sodium ophth soln 0.1% .... 90 diclofenac sodium tab delayed release 25 mg ................................................... 1 diclofenac sodium tab delayed release 50 mg ................................................... 1 diclofenac sodium tab delayed release 75 mg ................................................... 1 diclofenac sodium tab sr 24hr 100 mg .. 1 dicloxacillin sodium cap 250 mg ......... 17 dicloxacillin sodium cap 500 mg ......... 17 dicyclomine hcl cap 10 mg ................ 72 dicyclomine hcl oral soln 10 mg/5ml ... 72 dicyclomine hcl tab 20 mg ................. 72 didanosine delayed release capsule 125 mg ................................................... 9 didanosine delayed release capsule 200 mg ................................................... 9 didanosine delayed release capsule 250 mg ................................................... 9 didanosine delayed release capsule 400 mg ................................................... 9 DIFICID TAB 200MG ......................... 14 diflorasone diacetate cream 0.05%... 100 diflorasone diacetate oint 0.05% ...... 100 diflunisal tab 500 mg .......................... 1 digitek tab 0.125mg ......................... 34 digitek tab 0.25mg ........................... 34 digoxin inj 0.25 mg/ml ...................... 34 DIGOXIN ORAL SOLN 0.05 MG/ML ...... 34 digoxin tab 125 mcg (0.125 mg) ........ 34 digoxin tab 250 mcg (0.25 mg) .......... 34 dihydroergotamine mesylate inj 1 mg/ml ...................................................... 55 dilantin cap 100mg ........................... 39 dilantin cap 30mg ............................ 39 115 dilantin chw 50mg ............................39 DILANTIN-125 SUS 125/5ML ..............39 diltiazem hcl cap sr 12hr 120 mg ........32 diltiazem hcl cap sr 12hr 60 mg ..........32 diltiazem hcl cap sr 12hr 90 mg ..........32 diltiazem hcl cap sr 24hr 120 mg ........32 diltiazem hcl cap sr 24hr 180 mg ........32 diltiazem hcl cap sr 24hr 240 mg ........32 diltiazem hcl coated beads cap sr 24hr 120 mg ..................................................32 diltiazem hcl coated beads cap sr 24hr 180 mg ..................................................32 diltiazem hcl coated beads cap sr 24hr 240 mg ..................................................32 diltiazem hcl coated beads cap sr 24hr 300 mg ..................................................32 diltiazem hcl coated beads cap sr 24hr 360 mg ..................................................33 diltiazem hcl extended release beads cap sr 24hr 120 mg ................................33 diltiazem hcl extended release beads cap sr 24hr 180 mg ................................33 diltiazem hcl extended release beads cap sr 24hr 240 mg ................................33 diltiazem hcl extended release beads cap sr 24hr 300 mg ................................33 diltiazem hcl extended release beads cap sr 24hr 360 mg ................................33 diltiazem hcl extended release beads cap sr 24hr 420 mg ................................33 diltiazem hcl iv soln 125 mg/25ml (5 mg/ml) ............................................33 diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) ......................................................33 diltiazem hcl iv soln 50 mg/10ml (5 mg/ml) ............................................33 diltiazem hcl tab 120 mg ...................33 diltiazem hcl tab 30 mg .....................33 diltiazem hcl tab 60 mg .....................33 diltiazem hcl tab 90 mg .....................33 diltzac cap 120mg/24 ........................33 diltzac cap 180mg/24 ........................33 diltzac cap 240mg/24 ........................33 diltzac cap 300mg/24 ........................33 dimenhydrinate tab 50 mg .................71 diocto liq 50mg/5ml ..........................74 DIP/TET PED INJ 25-5LFU ..................85 DIPENTUM CAP 250MG ......................73 diphenhydramine hcl inj 50 mg/ml ..... 93 diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml ........................................... 76 diphenoxylate w/ atropine tab 2.5-0.025 mg ................................................. 76 disopyramide phosphate cap 100 mg .. 28 disopyramide phosphate cap 150 mg .. 28 disulfiram tab 250 mg ....................... 57 disulfiram tab 500 mg ....................... 57 DIURIL SUS 250/5ML........................ 35 divalproex sodium cap sprinkle 125 mg ...................................................... 39 divalproex sodium tab delayed release 125 mg ........................................... 39 divalproex sodium tab delayed release 250 mg ........................................... 39 divalproex sodium tab delayed release 500 mg ........................................... 39 divalproex sodium tab sr 24 hr 250 mg39 divalproex sodium tab sr 24 hr 500 mg39 DOCETAXEL FOR INJ CONC 20 MG/ML 19 DOCETAXEL FOR INJ CONC 80 MG/4ML (20 MG/ML) ..................................... 19 docetaxel inj 140/7ml ....................... 19 DOCETAXEL INJ 160/16ML ................ 19 DOCETAXEL INJ 200MG/20 ................ 19 DOCETAXEL INJ 20MG/2ML ............... 19 DOCETAXEL INJ 80MG/8ML ............... 19 docqlace cap 100mg ......................... 74 doc-q-lax tab 8.6-50mg .................... 74 docu liq 50mg/5ml ........................... 74 docusate sod cap 100mg ................... 74 docusate sodium cap 100 mg ............ 74 docusil cap 100mg ........................... 74 dok cap 100mg ................................ 74 dok cap 250mg ................................ 74 dok tab 100mg ................................ 74 donepezil hydrochloride orally disintegrating tab 10 mg ................... 43 donepezil hydrochloride orally disintegrating tab 5 mg ..................... 43 donepezil hydrochloride tab 10 mg ..... 43 donepezil hydrochloride tab 23 mg ..... 43 donepezil hydrochloride tab 5 mg ....... 43 dorzolamide hcl ophth soln 2% .......... 91 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml ......................... 91 double antib oin ............................... 97 116 doxazosin mesylate tab 1 mg .............26 doxazosin mesylate tab 2 mg .............26 doxazosin mesylate tab 4 mg .............26 doxazosin mesylate tab 8 mg .............26 doxepin hcl cap 10 mg.......................45 doxepin hcl cap 100 mg .....................45 doxepin hcl cap 150 mg .....................45 doxepin hcl cap 25 mg.......................45 doxepin hcl cap 50 mg.......................45 doxepin hcl cap 75 mg.......................45 doxepin hcl conc 10 mg/ml ................45 doxorubicin hcl for inj 50 mg ..............18 doxorubicin hcl inj 2 mg/ml ................18 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml .............................18 doxycycline hyclate cap 100 mg .........17 doxycycline hyclate cap 50 mg ...........17 doxycycline hyclate for inj 100 mg ......17 doxycycline hyclate tab 100 mg ..........17 doxycycline hyclate tab 20 mg ............17 doxycycline monohydrate cap 100 mg .17 doxycycline monohydrate cap 50 mg ...17 doxycycline monohydrate tab 100 mg .17 doxycycline monohydrate tab 150 mg .17 doxycycline monohydrate tab 50 mg ...17 doxycycline monohydrate tab 75 mg ...17 driminate tab 50mg ..........................71 dronabinol cap 10 mg ........................71 dronabinol cap 2.5 mg .......................71 dronabinol cap 5 mg .........................71 drospirenone-ethinyl estradiol tab 3-0.02 mg ..................................................62 DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG .................................62 drospirenone-ethinyl estradiol tab 3-0.03 mg ..................................................62 DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG .................................62 DROXIA CAP 200MG ..........................23 DROXIA CAP 300MG ..........................23 DROXIA CAP 400MG ..........................23 ducodyl tab 5mg ec ...........................74 DULERA AER 100-5MCG.....................96 DULERA AER 200-5MCG.....................96 duloxetine hcl enteric coated pellets cap 20 mg .............................................45 duloxetine hcl enteric coated pellets cap 30 mg .............................................45 duloxetine hcl enteric coated pellets cap 60 mg............................................. 45 DURAMORPH INJ 0.5MG/ML ................. 2 DURAMORPH INJ 1MG/ML ................... 2 DUREZOL EMU 0.05% ....................... 91 DYRENIUM CAP 100MG ..................... 35 DYRENIUM CAP 50MG ....................... 35 E e.e.s. 400 tab 400mg ....................... 14 E.E.S. GRAN SUS 200/5ML ................ 14 ear wax remv dro 6.5% ot .............. 103 ear wax remv sol 6.5% ot ............... 103 earwax remv sol 6.5% ot ................ 103 earwax trmnt dro 6.5% ot ............... 103 econazole nitrate cream 1% .............. 98 EDECRIN TAB 25MG ......................... 35 EDURANT TAB 25MG .......................... 9 EFFIENT TAB 10MG .......................... 82 EFFIENT TAB 5MG ............................ 82 ELIDEL CRE 1% ............................. 101 ELIQUIS TAB 2.5MG ......................... 79 ELIQUIS TAB 5MG ............................ 79 ELITEK INJ 1.5MG ............................ 23 ELITEK INJ 7.5MG ............................ 23 elixophyllin elx 80/15ml .................... 96 ELLA TAB 30MG ............................... 62 ELMIRON CAP 100MG ....................... 78 EMCYT CAP 140MG ........................... 18 EMEND CAP 125MG .......................... 71 EMEND CAP 40MG ............................ 71 EMEND CAP 80MG ............................ 71 EMEND PAK 80 & 125 ....................... 71 emoquette tab ................................. 62 EMSAM DIS 12MG/24H ..................... 45 EMSAM DIS 6MG/24HR ..................... 45 EMSAM DIS 9MG/24HR ..................... 45 EMTRIVA CAP 200MG.......................... 9 EMTRIVA SOL 10MG/ML ...................... 9 enalapril maleate & hydrochlorothiazide tab 10-25 mg .................................. 25 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg ................................. 25 enalapril maleate tab 10 mg .............. 25 enalapril maleate tab 2.5 mg ............. 25 enalapril maleate tab 20 mg .............. 25 enalapril maleate tab 5 mg ................ 25 endocet tab 10-325mg........................ 2 endocet tab 5-325mg ......................... 2 117 endocet tab 7.5-325 ........................... 2 ENGERIX-B INJ 10/0.5ML...................85 ENGERIX-B INJ 20MCG/ML .................85 enoxaparin sodium inj 100 mg/ml .......79 enoxaparin sodium inj 120 mg/0.8ml ..79 enoxaparin sodium inj 150 mg/ml .......79 enoxaparin sodium inj 30 mg/0.3ml ....79 enoxaparin sodium inj 300 mg/3ml .....79 enoxaparin sodium inj 40 mg/0.4ml ....79 enoxaparin sodium inj 60 mg/0.6ml ....79 enoxaparin sodium inj 80 mg/0.8ml ....79 enpresse-28 tab ...............................62 entacapone tab 200 mg .....................48 entecavir tab 0.5 mg .........................11 entecavir tab 1 mg ............................11 enulose sol 10gm/15 .........................74 EPIPEN 2-PAK INJ 0.3MG ...................95 EPIPEN-JR INJ 2-PAK .........................95 epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) ............................................18 epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) ............................................18 epitol tab 200mg ..............................39 EPIVIR HBV SOL 5MG/ML ...................11 EPIVIR SOL 10MG/ML ......................... 9 eplerenone tab 25 mg .......................26 eplerenone tab 50 mg .......................26 EPZICOM TAB 600-300 ......................10 ERAXIS INJ 100MG ............................ 7 ERAXIS INJ 50MG .............................. 7 ERIVEDGE CAP 150MG ......................20 errin tab 0.35mg ..............................62 ERYPED SUS 200/5ML .......................14 ERYPED SUS 400/5ML .......................14 ery-tab tab 250mg ec ........................14 ery-tab tab 333mg ec ........................14 ery-tab tab 500mg ec ........................14 erythrocin inj 500mg .........................14 erythrocin tab 250mg ........................14 erythromycin ethylsuccinate tab 400 mg ......................................................14 erythromycin gel 2% .........................97 erythromycin ophth oint 5 mg/gm.......90 erythromycin pads 2% ......................97 erythromycin soln 2% .......................97 erythromycin tab 250 mg...................14 erythromycin tab 500 mg...................14 erythromycin w/ delayed release particles cap 250 mg ..................................... 15 escitalopram oxalate soln 5 mg/5ml (base equiv) ............................................. 45 escitalopram oxalate tab 10 mg (base equiv) ............................................. 45 escitalopram oxalate tab 20 mg (base equiv) ............................................. 45 escitalopram oxalate tab 5 mg (base equiv) ............................................. 45 esomepra mag cap 40mg dr .............. 77 esomeprazole magnesium cap delayed release 20 mg (base eq) ................... 77 esomeprazole sodium for intravenous soln 20 mg (base equiv) .......................... 77 esomeprazole sodium for intravenous soln 40 mg (base equiv) .......................... 77 estradiol tab 0.5 mg ......................... 65 estradiol tab 1 mg ............................ 65 estradiol tab 2 mg ............................ 65 estradiol td patch weekly 0.025 mg/24hr ...................................................... 65 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) .............................. 65 estradiol td patch weekly 0.05 mg/24hr ...................................................... 65 estradiol td patch weekly 0.06 mg/24hr ...................................................... 65 estradiol td patch weekly 0.075 mg/24hr ...................................................... 65 estradiol td patch weekly 0.1 mg/24hr 65 ESTRADIOL VALERATE IM IN OIL 10 MG/ML ............................................ 65 estradiol valerate im in oil 20 mg/ml .. 65 ESTRADIOL VALERATE IM IN OIL 40 MG/ML ............................................ 65 ethambutol hcl tab 100 mg................ 11 ethambutol hcl tab 400 mg................ 11 ethosuximide cap 250 mg ................. 40 ethosuximide soln 250 mg/5ml .......... 40 etodolac cap 200 mg .......................... 1 etodolac cap 300 mg .......................... 1 etodolac tab 400 mg ........................... 1 etodolac tab 500 mg ........................... 1 etodolac tab sr 24hr 400 mg ................ 1 etodolac tab sr 24hr 500 mg ................ 1 etodolac tab sr 24hr 600 mg ................ 1 etoposide inj 500mg/25ml (20 mg/ml) 24 EURAX CRE 10% ............................ 102 118 EURAX LOT 10% ............................. 102 EVOTAZ TAB 300-150........................10 EXELON DIS 13.3/24 .........................43 EXELON DIS 4.6MG/24 ......................43 EXELON DIS 9.5MG/24 ......................43 exemestane tab 25 mg ......................20 EXJADE TAB 125MG ..........................61 EXJADE TAB 250MG ..........................61 EXJADE TAB 500MG ..........................61 EX-LAX TAB 15MG ............................74 F FABRAZYME INJ 35MG .......................64 FABRAZYME INJ 5MG.........................64 falmina tab ......................................62 famciclovir tab 125 mg ......................11 famciclovir tab 250 mg ......................11 famciclovir tab 500 mg ......................11 famotidine for susp 40 mg/5ml ...........72 famotidine in nacl 0.9% iv soln 20 mg/50ml .........................................73 famotidine inj 20 mg/2ml...................73 famotidine inj 200 mg/20ml ...............73 famotidine inj 40 mg/4ml...................73 famotidine tab 10 mg ........................73 famotidine tab 20 mg ........................73 famotidine tab 40 mg ........................73 FANAPT PAK .....................................50 FANAPT TAB 10MG ............................50 FANAPT TAB 12MG ............................50 FANAPT TAB 1MG ..............................50 FANAPT TAB 2MG ..............................50 FANAPT TAB 4MG ..............................50 FANAPT TAB 6MG ..............................50 FANAPT TAB 8MG ..............................50 FARESTON TAB 60MG ........................20 FARXIGA TAB 10MG ..........................59 FARXIGA TAB 5MG ............................59 FARYDAK CAP 10MG ..........................20 FARYDAK CAP 15MG ..........................20 FARYDAK CAP 20MG ..........................20 FASLODEX INJ 250MG .......................20 FAT EMULSION IV SOLN 20% .............87 FAZACLO TAB 100/ODT .....................50 FAZACLO TAB 12.5/ODT ....................50 FAZACLO TAB 150MG ........................50 FAZACLO TAB 200MG ........................50 FAZACLO TAB 25MG ODT ...................50 felbamate susp 600 mg/5ml ...............40 felbamate tab 400 mg ...................... 40 felbamate tab 600 mg ...................... 40 felodipine tab sr 24hr 10 mg .............. 33 felodipine tab sr 24hr 2.5 mg ............. 33 felodipine tab sr 24hr 5 mg ............... 33 fenofibrate micronized cap 130 mg ..... 30 fenofibrate micronized cap 134 mg ..... 30 fenofibrate micronized cap 200 mg ..... 30 fenofibrate micronized cap 43 mg....... 30 fenofibrate micronized cap 67 mg....... 30 fenofibrate tab 145 mg ..................... 30 fenofibrate tab 160 mg ..................... 30 fenofibrate tab 48 mg ....................... 30 fenofibrate tab 54 mg ....................... 30 fentanyl citrate lozenge on a handle 1200 mcg .................................................. 3 fentanyl citrate lozenge on a handle 1600 mcg .................................................. 3 fentanyl citrate lozenge on a handle 200 mcg .................................................. 2 fentanyl citrate lozenge on a handle 400 mcg .................................................. 2 fentanyl citrate lozenge on a handle 600 mcg .................................................. 3 fentanyl citrate lozenge on a handle 800 mcg .................................................. 3 fentanyl td patch 72hr 100 mcg/hr ....... 3 fentanyl td patch 72hr 12 mcg/hr ......... 3 fentanyl td patch 72hr 25 mcg/hr ......... 3 fentanyl td patch 72hr 50 mcg/hr ......... 3 fentanyl td patch 72hr 75 mcg/hr ......... 3 FENTORA TAB 100MCG ....................... 3 FENTORA TAB 200MCG ....................... 3 FENTORA TAB 400MCG ....................... 3 FENTORA TAB 600MCG ....................... 3 FENTORA TAB 800MCG ....................... 3 ferosul elx 220/5ml .......................... 81 FERROUS SUL LIQ 220/5ML ............... 81 FERROUS SULF TAB 324MG EC .......... 81 ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ....................... 81 ferrous sulfate tab 325 mg (65 mg elemental fe) ................................... 81 ferrous sulfate tab ec 325 mg (65 mg fe equivalent) ...................................... 81 FETZIMA CAP 120MG ........................ 46 FETZIMA CAP 20MG .......................... 45 FETZIMA CAP 40MG .......................... 46 119 FETZIMA CAP 80MG ..........................46 FETZIMA CAP TITRATIO .....................46 fiber laxatv tab 625mg ......................74 fiber laxtiv cap 0.52gm ......................74 fiber therap tab 500mg ......................74 fiber-caps tab 625mg ........................74 fiber-lax tab 625mg ..........................74 finasteride tab 5 mg ..........................78 FIRAZYR INJ 30MG/3ML .....................81 FLEBOGAMMA INJ 10/200ML ..............82 FLEBOGAMMA INJ 20/400ML ..............82 FLEBOGAMMA INJ 5% .......................82 FLEBOGAMMA INJ DIF 10% ................82 FLEBOGAMMA INJ DIF 5% .................82 flecainide acetate tab 100 mg .............28 flecainide acetate tab 150 mg .............28 flecainide acetate tab 50 mg ..............28 FLOVENT DISK AER 100MCG ..............95 FLOVENT DISK AER 250MCG ..............95 FLOVENT DISK AER 50MCG ................95 FLOVENT HFA AER 110MCG................95 FLOVENT HFA AER 220MCG................95 FLOVENT HFA AER 44MCG .................95 fluconazole for susp 10 mg/ml ............. 7 fluconazole for susp 40 mg/ml ............. 7 fluconazole in dextrose inj 200 mg/100ml ....................................................... 8 fluconazole in dextrose inj 400 mg/200ml ....................................................... 8 fluconazole in nacl 0.9% inj 200 mg/100ml ......................................... 8 fluconazole in nacl 0.9% inj 400 mg/200ml ......................................... 8 fluconazole tab 100 mg ...................... 8 fluconazole tab 150 mg ...................... 8 fluconazole tab 200 mg ...................... 8 fluconazole tab 50 mg ........................ 8 flucytosine cap 250 mg ....................... 8 flucytosine cap 500 mg ....................... 8 fludarabine phosphate for inj 50 mg ....19 fludarabine phosphate inj 25 mg/ml ....19 fludrocortisone acetate tab 0.1 mg ......66 flunisolide nasal soln 25 mcg/act (0.025%).........................................95 fluocin acet oil scalp ........................ 100 fluocinolone acetonide (otic) oil 0.01% .................................................... 103 fluocinolone acetonide cream 0.01% . 100 fluocinolone acetonide cream 0.025% 100 fluocinolone acetonide oil 0.01% (body oil) ............................................... 100 fluocinolone acetonide oint 0.025% .. 100 fluocinolone acetonide soln 0.01% ... 100 fluocinonide cream 0.05% ............... 100 fluocinonide emulsified base cream 0.05% .................................................... 100 fluocinonide gel 0.05% ................... 100 fluocinonide oint 0.05% .................. 100 fluocinonide soln 0.05% .................. 100 FLUOROMETHOLONE OPHTH SUSP 0.1% ...................................................... 91 fluorouracil cream 5% .................... 101 fluorouracil inj 1 gm/20ml (50 mg/ml) 19 fluorouracil inj 2.5 gm/50ml (50 mg/ml) ...................................................... 19 fluorouracil inj 5 gm/100ml (50 mg/ml) ...................................................... 19 fluorouracil inj 500 mg/10ml (50 mg/ml) ...................................................... 19 fluorouracil soln 2%........................ 101 fluorouracil soln 5%........................ 101 fluoxetine hcl cap 10 mg ................... 46 fluoxetine hcl cap 20 mg ................... 46 fluoxetine hcl cap 40 mg ................... 46 fluoxetine hcl solution 20 mg/5ml ...... 46 fluoxetine hcl tab 10 mg ................... 46 fluoxetine hcl tab 20 mg ................... 46 fluphenazine decanoate inj 25 mg/ml . 50 fluphenazine hcl elixir 2.5 mg/5ml ...... 50 fluphenazine hcl inj 2.5 mg/ml ........... 50 fluphenazine hcl oral conc 5 mg/ml .... 51 fluphenazine hcl tab 1 mg ................. 51 fluphenazine hcl tab 10 mg ............... 51 fluphenazine hcl tab 2.5 mg .............. 51 fluphenazine hcl tab 5 mg ................. 51 flurbiprofen sodium ophth soln 0.03% 91 flurbiprofen tab 100 mg ...................... 1 flurbiprofen tab 50 mg ........................ 1 flutamide cap 125 mg ....................... 20 fluticasone propionate cream 0.05% . 100 fluticasone propionate nasal susp 50 mcg/act .......................................... 95 fluticasone propionate oint 0.005% .. 100 fluvoxamine maleate tab 100 mg ....... 38 fluvoxamine maleate tab 25 mg ......... 38 fluvoxamine maleate tab 50 mg ......... 38 120 fondaparinux sodium subcutaneous inj 10 mg/0.8ml ........................................79 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml ...................................79 fondaparinux sodium subcutaneous inj 5 mg/0.4ml ........................................79 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml ...................................79 FORADIL CAP AEROLIZE ....................94 FORTEO SOL 600/2.4 ........................68 FORTICAL SPR 200/ACT .....................67 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg ................................25 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg ................................25 fosinopril sodium tab 10 mg ...............25 fosinopril sodium tab 20 mg ...............25 fosinopril sodium tab 40 mg ...............26 FOSRENOL CHW 1000MG ...................68 FOSRENOL CHW 500MG ....................68 FOSRENOL CHW 750MG ....................68 FREAMINE HBC INJ 6.9% ...................87 FREAMINE III INJ 10% ......................87 fungicure spr intens ..........................98 FUNGOID TINC SOL 2% .....................98 furosemide inj 10 mg/ml....................35 furosemide oral soln 10 mg/ml ...........35 furosemide sol 8mg/ml ......................35 furosemide tab 20 mg .......................35 furosemide tab 40 mg .......................35 furosemide tab 80 mg .......................35 FUZEON INJ 90MG ............................. 9 FYCOMPA TAB 10MG .........................40 FYCOMPA TAB 12MG .........................40 FYCOMPA TAB 2MG ...........................40 FYCOMPA TAB 4MG ...........................40 FYCOMPA TAB 6MG ...........................40 FYCOMPA TAB 8MG ...........................40 G gabapentin cap 100 mg .....................40 gabapentin cap 300 mg .....................40 gabapentin cap 400 mg .....................40 gabapentin oral soln 250 mg/5ml........40 gabapentin tab 600 mg .....................40 gabapentin tab 800 mg .....................40 GABITRIL TAB 12MG .........................40 GABITRIL TAB 16MG .........................40 galantamine hydrobromide cap sr 24hr 16 mg ................................................. 43 galantamine hydrobromide cap sr 24hr 24 mg ................................................. 43 galantamine hydrobromide cap sr 24hr 8 mg ................................................. 43 galantamine hydrobromide oral soln 4 mg/ml ............................................ 43 galantamine hydrobromide tab 12 mg 43 galantamine hydrobromide tab 4 mg .. 43 galantamine hydrobromide tab 8 mg .. 43 GAMASTAN S/D INJ .......................... 82 GAMMAGARD INJ 10GM/100 .............. 82 GAMMAGARD INJ 1GM/10ML ............. 82 GAMMAGARD INJ 2.5GM/25 .............. 82 GAMMAGARD INJ 20GM/200 .............. 82 GAMMAGARD INJ 30GM/300 .............. 82 GAMMAGARD INJ 5GM/50ML ............. 82 GAMMAGARD SD INJ 10GM HU .......... 83 GAMMAGARD SD INJ 2.5GM HU ......... 82 GAMMAGARD SD INJ 5GM HU ............ 83 GAMMAKED INJ 10GM/100 ................ 83 GAMMAKED INJ 1GM/10ML ................ 83 GAMMAKED INJ 2.5GM/25 ................. 83 GAMMAKED INJ 20GM/200 ................ 83 GAMMAKED INJ 5GM/50ML ................ 83 GAMMAPLEX INJ 10GM...................... 83 GAMMAPLEX INJ 2.5GM..................... 83 GAMMAPLEX INJ 5GM ....................... 83 GAMUNEX-C INJ 10GM/100 ............... 83 GAMUNEX-C INJ 1GM/10ML ............... 83 GAMUNEX-C INJ 2.5GM/25 ................ 83 GAMUNEX-C INJ 20GM/200 ............... 83 GAMUNEX-C INJ 40/400ML ................ 83 GAMUNEX-C INJ 5GM/50ML ............... 83 ganciclovir sodium for inj 500 mg ....... 11 GARDASIL 9 INJ ............................... 85 GARDASIL INJ ................................. 85 gatifloxacin ophth soln 0.5% ............. 90 GAUZE PADS 2" X 2" ........................ 59 gavilyte-c sol ................................... 74 gavilyte-g sol ................................... 74 gavilyte-n sol flav pk ........................ 74 GAVISCON CHW............................... 70 gemcitabine hcl for inj 1 gm .............. 19 gemcitabine hcl for inj 2 gm .............. 19 gemcitabine hcl for inj 200 mg ........... 19 GEMCITABINE INJ 1GM ..................... 19 GEMCITABINE INJ 200MG ................. 19 121 GEMCITABINE INJ 2GM......................19 gemfibrozil tab 600 mg ......................30 generlac sol 10gm/15 ........................74 gengraf cap 100mg ...........................84 gengraf cap 25mg .............................84 gengraf sol 100mg/ml .......................84 gentak oin 0.3% op...........................90 gentam/nacl inj 0.9mg/ml................... 5 gentam/nacl inj 1.4mg/ml................... 5 gentamicin in saline inj 0.8 mg/ml ....... 5 gentamicin in saline inj 1 mg/ml .......... 5 gentamicin in saline inj 1.2 mg/ml ....... 5 gentamicin in saline inj 1.6 mg/ml ....... 5 gentamicin in saline inj 2 mg/ml .......... 5 gentamicin sulfate cream 0.1% ..........97 gentamicin sulfate inj 10 mg/ml .......... 5 gentamicin sulfate inj 40 mg/ml .......... 5 gentamicin sulfate iv soln 10 mg/ml ..... 5 gentamicin sulfate oint 0.1% ..............97 gentamicin sulfate ophth oint 0.3% .....90 gentamicin sulfate ophth soln 0.3% ....90 GENTEAL GEL 0.3% ..........................92 GEODON INJ 20MG ...........................51 gildagia tab 0.4-35 ............................62 gildess tab 1.5/30 .............................62 GILENYA CAP 0.5MG .........................56 GILOTRIF TAB 20MG .........................21 GILOTRIF TAB 30MG .........................21 GILOTRIF TAB 40MG .........................21 glatiramer acetate soln prefilled syringe 20 mg/ml.........................................56 GLEEVEC TAB 100MG ........................21 GLEEVEC TAB 400MG ........................21 GLEOSTINE CAP 100MG .....................18 GLEOSTINE CAP 10MG ......................18 GLEOSTINE CAP 40MG ......................18 glimepiride tab 1 mg .........................59 glimepiride tab 2 mg .........................59 glimepiride tab 4 mg .........................59 glipizide tab 10 mg ...........................59 glipizide tab 5 mg .............................59 glipizide tab sr 24hr 10 mg ................59 glipizide tab sr 24hr 2.5 mg ...............59 glipizide tab sr 24hr 5 mg ..................59 glipizide-metformin hcl tab 2.5-250 mg ......................................................60 glipizide-metformin hcl tab 2.5-500 mg ......................................................60 glipizide-metformin hcl tab 5-500 mg . 60 GLUCAGEN INJ HYPOKIT ................... 67 GLUCAGON KIT 1MG ........................ 67 GLUCOSE CHW 4GM ......................... 67 glutose 15 gel 40% .......................... 67 glycerin sup 2.1gm ........................... 74 glycerin sup 2gm ............................. 74 glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) ...................................................... 72 glycopyrrolate tab 1 mg .................... 72 glycopyrrolate tab 2 mg .................... 72 gnp antacid chw 1000mg .................. 70 gnp antacid sus anti-gas ................... 70 gnp antacid sus cherry ...................... 70 gnp ear dro 6.5% ot ....................... 103 gnp ear sys sol 6.5% ot .................. 103 gnp glycerin sup 2.1gm..................... 74 gnp iron tab 65mg............................ 81 gnp k-pec sus 262/15ml ................... 71 gnp masanti sus max st .................... 70 gnp masanti sus reg st...................... 70 gnp milk mag sus ............................. 74 gnp nicotine gum 2mg mint ............... 57 gnp nicotine gum 2mg orig ................ 57 gnp nicotine gum 4mg mint ............... 57 gnp nicotine gum 4mg orig ................ 57 gnp nicotine loz 2mg mint ................. 57 gnp nicotine loz 4mg mint ................. 57 gnp pediatri sol electrol ..................... 86 gnp triple oin antibiot ....................... 97 gnp vit a&d oin .............................. 101 GOLYTELY SOL................................. 74 granisetron hcl inj 0.1 mg/ml............. 71 granisetron hcl inj 1 mg/ml ............... 71 granisetron hcl inj 4 mg/4ml (1 mg/ml) ...................................................... 71 granisetron hcl tab 1 mg ................... 71 GRANIX INJ 300/0.5 ......................... 80 GRANIX INJ 480/0.8 ......................... 80 griseofulvin microsize susp 125 mg/5ml 8 griseofulvin microsize tab 500 mg ........ 8 griseofulvin ultramicrosize tab 125 mg .. 8 griseofulvin ultramicrosize tab 250 mg .. 8 guanfacine hcl tab sr 24hr 1 mg (base equiv) ............................................. 54 guanfacine hcl tab sr 24hr 2 mg (base equiv) ............................................. 54 guanfacine hcl tab sr 24hr 3 mg (base 122 equiv) .............................................54 guanfacine hcl tab sr 24hr 4 mg (base equiv) .............................................54 H halobetasol propionate cream 0.05% 100 halobetasol propionate oint 0.05% .... 100 haloperidol decanoate im soln 100 mg/ml ......................................................51 haloperidol decanoate im soln 50 mg/ml ......................................................51 haloperidol lactate inj 5 mg/ml ...........51 haloperidol lactate oral conc 2 mg/ml ..51 haloperidol tab 0.5 mg ......................51 haloperidol tab 1 mg .........................51 haloperidol tab 10 mg .......................51 haloperidol tab 2 mg .........................51 haloperidol tab 20 mg .......................51 haloperidol tab 5 mg .........................51 HARVONI TAB 90-400MG ...................11 HAVRIX INJ 1440UNIT .......................85 HAVRIX INJ 720UNIT.........................85 heartburn tab relief ...........................73 heather tab 0.35mg ..........................62 HEMORRHOIDAL OIN....................... 101 hemorrhoidal sup ............................ 101 HEP SOD/D5W INJ 25000UNT ............79 HEP SOD/NACL INJ 25000UNT ............80 HEPARIN SOD INJ 2000/ML ................80 HEPARIN SOD INJ 2500/ML ................80 HEPARIN SODIUM (PORCINE) 40 UNIT/ML IN D5W ...........................................80 heparin sodium (porcine) inj 1000 unit/ml ......................................................80 heparin sodium (porcine) inj 10000 unit/ml ............................................80 heparin sodium (porcine) inj 20000 unit/ml ............................................80 heparin sodium (porcine) inj 5000 unit/ml ......................................................80 HEPATAMINE SOL 8% .......................87 HERCEPTIN INJ 440MG ......................20 HEXALEN CAP 50MG ..........................18 HIBERIX SOL 10MCG .........................85 hm antacid sus anti-gas .....................70 hm fiber pow 48.57% ........................74 HM GLUCOSE CHW ORANGE...............67 hm povid-iod sol 10% ..................... 101 hm saline spr 0.65% .........................95 hm triple oin antibiot ........................ 97 HUMIRA INJ 10MG/0.2 ...................... 82 HUMIRA KIT 20MG/0.4 ..................... 82 HUMIRA KIT 40MG/0.8 ..................... 82 HUMIRA PEN INJ 40MG/0.8 ............... 82 HUMIRA PEN INJ CROHNS ................. 82 HUMIRA PEN INJ PSORIASI ............... 82 HUMULIN R INJ U-500 ...................... 59 hydralazine hcl inj 20 mg/ml ............. 36 hydralazine hcl tab 10 mg ................. 36 hydralazine hcl tab 100 mg ............... 36 hydralazine hcl tab 25 mg ................. 36 hydralazine hcl tab 50 mg ................. 36 hydro skin lot 1% ........................... 100 hydrochlorothiazide cap 12.5 mg ........ 35 hydrochlorothiazide tab 12.5 mg ........ 35 hydrochlorothiazide tab 25 mg ........... 35 hydrochlorothiazide tab 50 mg ........... 35 hydrocodone-acetaminophen soln 7.5-325 mg/15ml ............................... 2 hydrocodone-acetaminophen tab 10-325 mg ................................................... 2 hydrocodone-acetaminophen tab 5-325 mg ................................................... 2 hydrocodone-acetaminophen tab 7.5-325 mg ................................................... 2 hydrocodone-ibuprofen tab 7.5-200 mg 2 hydrocort cre 0.5% ........................ 100 hydrocort/ cre aloe 1% ................... 100 hydrocortisone butyrate cream 0.1% 100 hydrocortisone butyrate oint 0.1% ... 100 hydrocortisone butyrate soln 0.1% ... 100 hydrocortisone cream 0.5% ............. 100 hydrocortisone cream 1% ............... 100 hydrocortisone cream 2.5% ............. 100 hydrocortisone enema 100 mg/60ml .. 73 HYDROCORTISONE ENEMA 100 MG/60ML ...................................................... 73 hydrocortisone lotion 1% ................ 100 hydrocortisone lotion 2.5%.............. 100 hydrocortisone oint 1% ................... 100 hydrocortisone oint 2.5% ................ 100 hydrocortisone rectal cream 2.5% ...... 98 hydrocortisone tab 10 mg ................. 66 hydrocortisone tab 20 mg ................. 66 hydrocortisone tab 5 mg ................... 66 hydrocortisone valerate cream 0.2% 100 hydrocortisone valerate oint 0.2% .... 100 123 hydrocortisone-aloe vera cream 0.5%100 hydromorphone hcl liqd 1 mg/ml ......... 3 hydromorphone hcl preservative free (pf) inj 10 mg/ml ..................................... 3 hydromorphone hcl tab 2 mg .............. 3 hydromorphone hcl tab 4 mg .............. 3 hydromorphone hcl tab 8 mg .............. 3 hydroxychloroquine sulfate tab 200 mg ......................................................82 hydroxyurea cap 500 mg ...................23 hydroxyzine hcl im soln 25 mg/ml .......93 hydroxyzine hcl im soln 50 mg/ml .......93 hydroxyzine hcl syrup 10 mg/5ml .......93 hydroxyzine hcl tab 10 mg .................93 hydroxyzine hcl tab 25 mg .................93 hydroxyzine hcl tab 50 mg .................93 hydroxyzine pamoate cap 100 mg .......93 hydroxyzine pamoate cap 25 mg ........93 hydroxyzine pamoate cap 50 mg ........93 I ibandronate sodium tab 150 mg (base equivalent) ......................................61 IBRANCE CAP 100MG ........................20 IBRANCE CAP 125MG ........................20 IBRANCE CAP 75MG ..........................20 ibuprofen susp 100 mg/5ml ................ 1 ibuprofen tab 400 mg ......................... 1 ibuprofen tab 600 mg ......................... 1 ibuprofen tab 800 mg ......................... 1 ICLUSIG TAB 15MG ...........................22 ICLUSIG TAB 45MG ...........................22 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) ......................................................19 idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) ......................................................19 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) ......................................................18 IFEX INJ 3GM ...................................18 ifosfamide for inj 1 gm ......................18 IFOSFAMIDE INJ 3GM ........................18 ifosfamide iv inj 1 gm/20ml (50 mg/ml) ......................................................18 ifosfamide iv inj 3 gm/60ml (50 mg/ml) ......................................................18 ILEVRO DRO 0.3% OP .......................91 ilotycin oin op ...................................90 IMBRUVICA CAP 140MG .....................22 imipenem-cilastatin intravenous for soln 250 mg ............................................. 6 imipenem-cilastatin intravenous for soln 500 mg ............................................. 6 imipramine hcl tab 10 mg ................. 46 imipramine hcl tab 25 mg ................. 46 imipramine hcl tab 50 mg ................. 46 imiquimod cream 5%...................... 101 IMOVAX RABIE INJ 2.5/ML ................ 85 INCRELEX INJ 40MG/4ML .................. 67 indapamide tab 1.25 mg ................... 35 indapamide tab 2.5 mg ..................... 35 INFANRIX INJ .................................. 85 INLYTA TAB 1MG .............................. 22 INLYTA TAB 5MG .............................. 22 insta-glucos gel 77.4% ..................... 67 INSULIN PEN NEEDLE ....................... 59 INSULIN SAFETY NEEDLES ................ 59 INSULIN SYRINGE ............................ 59 INTELENCE TAB 100MG ...................... 9 INTELENCE TAB 200MG ...................... 9 INTELENCE TAB 25MG ........................ 9 INTRALIPID INJ 20% ........................ 87 INTRALIPID INJ 30% ........................ 87 INTRON A INJ 10MU ......................... 83 INTRON A INJ 18MU ......................... 83 INTRON A INJ 25MU ......................... 83 INTRON A INJ 50MU ......................... 83 introvale tab .................................... 62 INVANZ INJ 1GM ................................ 6 INVEGA SUST INJ 117/0.75 ............... 51 INVEGA SUST INJ 156MG/ML ............. 51 INVEGA SUST INJ 234/1.5 ................ 51 INVEGA SUST INJ 39/0.25 ................ 51 INVEGA SUST INJ 78/0.5ML .............. 51 INVEGA TAB 1.5MG .......................... 51 INVEGA TAB 3MG ............................. 51 INVEGA TAB 6MG ............................. 51 INVEGA TAB 9MG ............................. 51 INVIRASE CAP 200MG ........................ 9 INVIRASE TAB 500MG ........................ 9 INVOKAMET TAB 150-1000 ............... 60 INVOKAMET TAB 150-500 ................. 60 INVOKAMET TAB 50-1000 ................. 60 INVOKAMET TAB 50-500MG .............. 60 INVOKANA TAB 100MG ..................... 60 INVOKANA TAB 300MG ..................... 60 IONOSOL-B/ INJ D5W ....................... 88 IONOSOL-MB INJ /D5W .................... 88 124 IPOL INJ INACTIVE............................85 ipratropium bromide inhal soln 0.02% .93 ipratropium bromide nasal soln 0.03% (21 mcg/spray) ......................................93 ipratropium bromide nasal soln 0.06% (42 mcg/spray) ......................................93 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml ............................93 IRESSA TAB 250MG ..........................22 irinotecan hcl inj 100 mg/5ml (20 mg/ml) ......................................................24 irinotecan hcl inj 40 mg/2ml (20 mg/ml) ......................................................24 irinotecan hcl inj 500 mg/25ml (20 mg/ml) ............................................24 iron supplem tab therapy ...................81 iron therapy tab 200mg .....................81 ISENTRESS CHW 100MG..................... 9 ISENTRESS CHW 25MG ...................... 9 ISENTRESS POW 100MG ..................... 9 ISENTRESS TAB 400MG ...................... 9 ISOLYTE-P INJ /D5W .........................88 isolyte-s inj ......................................88 isoniazid inj 100 mg/ml .....................11 isoniazid syrup 50 mg/5ml .................11 isoniazid tab 100 mg .........................11 isoniazid tab 300 mg .........................11 ISOPTO TEARS SOL 0.5% OP .............92 isosorbide dinitrate tab 10 mg ............36 isosorbide dinitrate tab 20 mg ............36 isosorbide dinitrate tab 30 mg ............36 isosorbide dinitrate tab 5 mg ..............36 isosorbide dinitrate tab cr 40 mg ........36 isosorbide mononitrate tab 10 mg .......36 isosorbide mononitrate tab 20 mg .......36 isosorbide mononitrate tab sr 24hr 120 mg ..................................................36 isosorbide mononitrate tab sr 24hr 30 mg ......................................................36 isosorbide mononitrate tab sr 24hr 60 mg ......................................................36 isradipine cap 2.5 mg ........................33 isradipine cap 5 mg ...........................33 ISTALOL SOL 0.5% OP ......................91 ISTODAX INJ 10MG ...........................20 itraconazole cap 100 mg ..................... 8 ivermectin tab 3 mg ........................... 6 IXIARO INJ ......................................85 J JAKAFI TAB 10MG ............................ 22 JAKAFI TAB 15MG ............................ 22 JAKAFI TAB 20MG ............................ 22 JAKAFI TAB 25MG ............................ 22 JAKAFI TAB 5MG .............................. 22 JALYN CAP....................................... 78 jantoven tab 10mg ........................... 80 jantoven tab 1mg ............................. 80 jantoven tab 2.5mg .......................... 80 jantoven tab 2mg ............................. 80 jantoven tab 3mg ............................. 80 jantoven tab 4mg ............................. 80 jantoven tab 5mg ............................. 80 jantoven tab 6mg ............................. 80 jantoven tab 7.5mg .......................... 80 JANUMET TAB 50-1000 ..................... 60 JANUMET TAB 50-500MG .................. 60 JANUMET XR TAB 100-1000............... 60 JANUMET XR TAB 50-1000 ................ 60 JANUMET XR TAB 50-500MG.............. 60 JANUVIA TAB 100MG ........................ 60 JANUVIA TAB 25MG .......................... 60 JANUVIA TAB 50MG .......................... 60 JENTADUETO TAB 2.5-1000 ............... 60 JENTADUETO TAB 2.5-500 ................ 60 JENTADUETO TAB 2.5-850 ................ 60 JOLIVETTE TAB 0.35MG .................... 62 junel 1.5/30 tab ............................... 62 junel 1/20 tab .................................. 62 junel fe tab 1.5/30 ........................... 62 junel fe tab 1/20 .............................. 62 K KADCYLA INJ 100MG ........................ 20 KADCYLA INJ 160MG ........................ 20 KALETRA SOL .................................. 10 KALETRA TAB 100-25MG ................... 10 KALETRA TAB 200-50MG ................... 10 kao-tin cap 240mg ........................... 74 kao-tin sus 262/15ml ....................... 71 kariva tab 28 day ............................. 62 KCL 10 MEQ/L (0.075%) IN DEXTROSE 5% & NACL 0.45% INJ...................... 88 KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & NACL 0.2% INJ ............................. 88 KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & NACL 0.33% INJ ........................... 88 KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% 125 & NACL 0.45% INJ ............................88 KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & NACL 0.9% INJ ..............................88 kcl 20 meq/l (0.15%) in nacl 0.45% inj ......................................................88 KCL 20 MEQ/L (0.15%) IN NACL 0.45% INJ ..................................................88 KCL 20 MEQ/L (0.15%) IN NACL 0.9% INJ ......................................................88 KCL 30 MEQ/L (0.224%) IN DEXTROSE 5% & NACL 0.45% INJ ......................88 KCL 40 MEQ/L (0.3%) IN DEXTROSE 5% & NACL 0.45% INJ ...............................88 KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ ......................................................88 KCL/D5W/NACL INJ 0.15/0.2..............88 KCL/D5W/NACL INJ 0.3/0.9% ............88 ketoconazole cream 2% .....................98 ketoconazole shampoo 2% .................99 ketoconazole tab 200 mg .................... 8 ketoprofen cap 50 mg ........................ 1 ketoprofen cap 75 mg ........................ 1 ketorolac tromethamine ophth soln 0.4% ......................................................91 ketorolac tromethamine ophth soln 0.5% ......................................................91 kimidess tab.....................................62 KINRIX INJ.......................................85 kionex pow ......................................61 kionex sus 15gm/60 ..........................61 KLOR-CON 10 TAB 10MEQ ER .............86 KLOR-CON 8 TAB 8MEQ ER ................86 klor-con m15 tab 15meq er ................86 klor-con pow 20meq..........................86 konsyl cap 520mg .............................74 konsyl pow 30.9% ............................74 KONSYL-D POW 52.3%......................74 KUVAN POW 100MG ..........................64 KUVAN POW 500MG ..........................64 KUVAN TAB 100MG ...........................64 L labetalol hcl tab 100 mg ....................31 labetalol hcl tab 200 mg ....................31 labetalol hcl tab 300 mg ....................31 laclotion lot 12%............................. 102 LACTATED RINGER'S SOLUTION .........88 lactic acid (ammonium lactate) cream 12% .............................................. 102 lactic acid (ammonium lactate) lotion 12% .................................................... 102 lactulose (encephalopathy) solution 10 gm/15ml ......................................... 74 lactulose solution 10 gm/15ml ........... 74 lamivudine oral soln 10 mg/ml ............. 9 lamivudine tab 100 mg (hbv)............. 11 lamivudine tab 150 mg ....................... 9 lamivudine tab 300 mg ....................... 9 lamivudine-zidovudine tab 150-300 mg ...................................................... 10 lamotrigine tab 100 mg ..................... 40 lamotrigine tab 150 mg ..................... 40 lamotrigine tab 200 mg ..................... 40 lamotrigine tab 25 mg ...................... 40 lamotrigine tab chewable dispersible 25 mg ................................................. 40 lamotrigine tab chewable dispersible 5 mg ...................................................... 40 lamotrigine tab sr 24hr 100 mg.......... 40 lamotrigine tab sr 24hr 200 mg.......... 40 lamotrigine tab sr 24hr 25 mg ........... 40 lamotrigine tab sr 24hr 250 mg.......... 40 lamotrigine tab sr 24hr 300 mg.......... 40 lamotrigine tab sr 24hr 50 mg ........... 40 LANOXIN TAB 0.125MG ..................... 34 LANOXIN TAB 0.25MG ...................... 34 LANTUS INJ 100/ML ......................... 59 LANTUS INJ SOLOSTAR ..................... 59 larin fe tab 1.5/30 ............................ 62 larin fe tab 1/20 ............................... 62 larin tab 1.5/30 ................................ 62 larin tab 1/20 .................................. 62 LASTACAFT SOL 0.25%..................... 91 latanoprost ophth soln 0.005% .......... 91 LATUDA TAB 120MG ......................... 51 LATUDA TAB 20MG ........................... 51 LATUDA TAB 40MG ........................... 51 LATUDA TAB 60MG ........................... 51 LATUDA TAB 80MG ........................... 51 lax/stl soft tab 8.6-50mg .................. 74 laxative sup 10mg ............................ 74 LAZANDA SPR 100MCG ....................... 3 LAZANDA SPR 400MCG ....................... 3 leflunomide tab 10 mg ...................... 82 leflunomide tab 20 mg ...................... 82 LENVIMA CAP 10MG ......................... 22 LENVIMA CAP 14MG ......................... 22 126 LENVIMA CAP 20MG ..........................22 LENVIMA CAP 24MG ..........................22 lessina tab .......................................62 LETAIRIS TAB 10MG ..........................37 LETAIRIS TAB 5MG ...........................37 letrozole tab 2.5 mg ..........................20 leucovorin calcium for inj 100 mg .......23 leucovorin calcium for inj 200 mg .......23 leucovorin calcium for inj 350 mg .......24 leucovorin calcium for inj 50 mg .........23 leucovorin calcium tab 10 mg .............24 leucovorin calcium tab 15 mg .............24 leucovorin calcium tab 25 mg .............24 leucovorin calcium tab 5 mg ...............24 leucovorin inj calcium ........................24 LEUKERAN TAB 2MG..........................18 LEUKINE INJ 250MCG ........................80 leuprolide acetate inj kit 5 mg/ml .......20 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) ......................94 LEVEMIR INJ ....................................59 LEVEMIR INJ FLEXTOUC .....................59 LEVETIRACETA INJ 10MG/ML..............40 LEVETIRACETA INJ 15MG/ML..............40 LEVETIRACETA INJ 5MG/ML ...............40 levetiracetam inj 500 mg/5ml (100 mg/ml) ............................................40 levetiracetam oral soln 100 mg/ml ......40 levetiracetam tab 1000 mg ................41 levetiracetam tab 250 mg ..................40 levetiracetam tab 500 mg ..................41 levetiracetam tab 750 mg ..................41 levetiracetam tab sr 24hr 500 mg .......41 levetiracetam tab sr 24hr 750 mg .......41 LEVOBUNOLOL HCL OPHTH SOLN 0.25% ......................................................91 levobunolol hcl ophth soln 0.5% .........91 levocarnitine inj 200 mg/ml ...............64 levocarnitine oral soln 1 gm/10ml (10%) ......................................................64 levocarnitine tab 330 mg ...................64 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) .........................93 levocetirizine dihydrochloride tab 5 mg 93 levofloxacin in d5w iv soln 250 mg/50ml ......................................................15 levofloxacin in d5w iv soln 500 mg/100ml ......................................................15 levofloxacin in d5w iv soln 750 mg/150ml ...................................................... 15 levofloxacin iv soln 25 mg/ml ............ 15 levofloxacin oral soln 25 mg/ml.......... 15 levofloxacin tab 250 mg .................... 15 levofloxacin tab 500 mg .................... 15 levofloxacin tab 750 mg .................... 15 levonest tab .................................... 62 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg ............... 62 LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG ...................................................... 62 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg ..................................... 62 levonorgestrel tab 0.75 mg ............... 62 levonorgestrel tab 1.5 mg ................. 62 levora-28 tab 0.15/30....................... 62 levothyroxine sodium tab 100 mcg ..... 68 levothyroxine sodium tab 112 mcg ..... 68 levothyroxine sodium tab 125 mcg ..... 69 levothyroxine sodium tab 137 mcg ..... 69 levothyroxine sodium tab 150 mcg ..... 69 levothyroxine sodium tab 175 mcg ..... 69 levothyroxine sodium tab 200 mcg ..... 69 levothyroxine sodium tab 25 mcg ....... 68 levothyroxine sodium tab 300 mcg ..... 69 levothyroxine sodium tab 50 mcg ....... 68 levothyroxine sodium tab 75 mcg ....... 68 levothyroxine sodium tab 88 mcg ....... 68 LEVOXYL TAB 100MCG ...................... 69 LEVOXYL TAB 112MCG ...................... 69 LEVOXYL TAB 125MCG ...................... 69 LEVOXYL TAB 137MCG ...................... 69 LEVOXYL TAB 150MCG ...................... 69 LEVOXYL TAB 175MCG ...................... 69 LEVOXYL TAB 200MCG ...................... 69 LEVOXYL TAB 25MCG........................ 69 LEVOXYL TAB 50MCG........................ 69 LEVOXYL TAB 75MCG........................ 69 LEVOXYL TAB 88MCG........................ 69 LEXIVA SUS 50MG/ML ........................ 9 LEXIVA TAB 700MG ............................ 9 LIALDA TAB 1.2GM ........................... 73 lice treatmt sha 0.33-4% ................ 102 lidocaine hcl gel 2% ....................... 101 lidocaine hcl local inj 0.5% .................. 5 lidocaine hcl local inj 1% ..................... 5 127 lidocaine hcl local inj 1.5% .................. 5 lidocaine hcl local inj 2%..................... 5 lidocaine hcl local preservative free (pf) inj 0.5% ................................................ 5 lidocaine hcl local preservative free (pf) inj 1% .................................................. 5 lidocaine hcl soln 4% ....................... 101 lidocaine hcl viscous soln 2% ........... 103 lidocaine oint 5% ............................ 101 lidocaine patch 5%.......................... 101 lidocaine-prilocaine cream 2.5-2.5% . 101 lidocream cre 4% ............................ 101 linezolid iv soln 2 mg/ml ..................... 6 LINEZOLID TAB 600 MG ..................... 6 LINZESS CAP 145MCG .......................76 LINZESS CAP 290MCG .......................76 liothyronine sodium tab 25 mcg ..........69 liothyronine sodium tab 5 mcg............69 liothyronine sodium tab 50 mcg ..........69 liquitears sol ....................................92 lisinopril & hydrochlorothiazide tab 10-12.5 mg ......................................25 lisinopril & hydrochlorothiazide tab 20-12.5 mg ......................................25 lisinopril & hydrochlorothiazide tab 20-25 mg ..................................................25 lisinopril tab 10 mg ...........................26 lisinopril tab 2.5 mg ..........................26 lisinopril tab 20 mg ...........................26 lisinopril tab 30 mg ...........................26 lisinopril tab 40 mg ...........................26 lisinopril tab 5 mg .............................26 lithium carbonate cap 150 mg ............56 lithium carbonate cap 300 mg ............56 lithium carbonate cap 600 mg ............56 lithium carbonate tab 300 mg.............56 lithium carbonate tab cr 300 mg .........56 lithium carbonate tab cr 450 mg .........56 LITHIUM SOL 8MEQ/5ML....................56 LOKARA LOT 0.05% ........................ 100 LOMUSTINE CAP 10 MG .....................18 LOMUSTINE CAP 100 MG ...................18 LOMUSTINE CAP 40 MG .....................18 loperamide hcl cap 2 mg ....................76 loperamide hcl liq 1 mg/5ml (0.2 mg/ml) ......................................................71 loperamide hcl liq 1 mg/7.5ml ............71 loperamide sus 1mg/7.5 ....................71 lorazepam con 2mg/ml ..................... 38 lorazepam inj 2 mg/ml ...................... 38 lorazepam inj 4 mg/ml ...................... 38 lorazepam tab 0.5 mg ....................... 38 lorazepam tab 1 mg ......................... 38 lorazepam tab 2 mg ......................... 38 loryna tab 3-0.02mg ......................... 63 losartan potassium & hydrochlorothiazide tab 100-12.5 mg .............................. 27 losartan potassium & hydrochlorothiazide tab 100-25 mg................................. 27 losartan potassium & hydrochlorothiazide tab 50-12.5 mg................................ 27 losartan potassium tab 100 mg .......... 28 losartan potassium tab 25 mg ............ 28 losartan potassium tab 50 mg ............ 28 LOTEMAX GEL 0.5% ......................... 91 LOTEMAX OIN 0.5% ......................... 91 LOTEMAX SUS 0.5% ......................... 91 LOTRONEX TAB 0.5MG ...................... 76 LOTRONEX TAB 1MG ........................ 76 lovastatin tab 10 mg......................... 29 lovastatin tab 20 mg......................... 29 lovastatin tab 40 mg......................... 29 low-ogestrel tab ............................... 63 loxapine succinate cap 10 mg ............ 51 loxapine succinate cap 25 mg ............ 51 loxapine succinate cap 5 mg .............. 51 loxapine succinate cap 50 mg ............ 51 lubricant dro eye .............................. 92 lubrifresh oin p.m. ............................ 92 LUMIGAN SOL 0.01% ....................... 91 LUMIZYME INJ 50MG ........................ 64 LUPR DEP-PED INJ 11.25MG .............. 21 LUPR DEP-PED INJ 15MG .................. 21 LUPR DEP-PED INJ 30MG .................. 21 LUPR DEP-PED INJ 7.5MG ................. 20 LUPRON DEPOT INJ 11.25MG............. 21 LUPRON DEPOT INJ 3.75MG .............. 21 lutera tab ........................................ 63 LYNPARZA CAP 50MG ....................... 20 LYRICA CAP 100MG .......................... 41 LYRICA CAP 150MG .......................... 41 LYRICA CAP 200MG .......................... 41 LYRICA CAP 225MG .......................... 41 LYRICA CAP 25MG ............................ 41 LYRICA CAP 300MG .......................... 41 LYRICA CAP 50MG ............................ 41 128 LYRICA CAP 75MG ............................41 LYRICA SOL 20MG/ML .......................41 LYSODREN TAB 500MG ......................21 lyza tab 0.35mg ...............................63 M maalox advan sus max st ..................70 MAGNESIUM SU INJ 20/500ML ...........86 MAGNESIUM SU INJ 80MG/ML ............86 magnesium sulfate inj 50% ................86 MAGNESIUM SULFATE INJ 50% ..........86 malathion lotion 0.5% ..................... 102 maprotiline hcl tab 25 mg ..................46 maprotiline hcl tab 50 mg ..................46 maprotiline hcl tab 75 mg ..................46 marlissa tab 0.15/30 .........................63 MARPLAN TAB 10MG .........................46 MATULANE CAP 50MG .......................23 MAXIDEX SUS 0.1% OP .....................91 meclizine hcl tab 12.5 mg ..................72 meclizine hcl tab 25 mg .....................72 medi-cort cre 1% ............................ 100 medroxyprogesterone acetate im susp 150 mg/ml .......................................63 medroxyprogesterone acetate tab 10 mg ......................................................68 medroxyprogesterone acetate tab 2.5 mg ......................................................68 medroxyprogesterone acetate tab 5 mg ......................................................68 mefloquine hcl tab 250 mg .................. 8 MEGACE ES SUS 625/5ML ..................21 megestrol acetate susp 40 mg/ml .......21 MEGESTROL ACETATE SUSP 625 MG/5ML ......................................................21 megestrol acetate tab 20 mg ..............21 megestrol acetate tab 40 mg ..............21 MEKINIST TAB 0.5MG ........................22 MEKINIST TAB 2MG ..........................22 MELOXICAM SUSP 7.5 MG/5ML ............ 1 meloxicam tab 15 mg ......................... 2 meloxicam tab 7.5 mg ........................ 1 melphalan hcl for inj 50 mg (base equiv) ......................................................18 MEMANTINE HCL TAB 10 MG ..............43 memantine hcl tab 5 mg ....................43 MENACTRA INJ .................................85 MENOMUNE INJ A/C/Y/W ...................85 MENVEO INJ .....................................85 mercaptopurine tab 50 mg ................ 19 meropenem iv for soln 1 gm ................ 6 meropenem iv for soln 500 mg ............ 6 mesalamine enema 4 gm .................. 73 mesalamine rectal enema 4 gm & cleanser wipe kit ........................................... 73 mesna inj 100 mg/ml ....................... 24 MESNEX TAB 400MG......................... 24 metamucil pow 28.3%org ................. 74 metamucil pow 58.6% ...................... 74 metamucil pow 58.6%org ................. 74 metformin hcl tab 1000 mg ............... 60 metformin hcl tab 500 mg ................. 60 metformin hcl tab 850 mg ................. 60 metformin hcl tab sr 24hr 500 mg ...... 60 metformin hcl tab sr 24hr 750 mg ...... 60 methadone con 10mg/ml .................... 3 methadone hcl soln 10 mg/5ml ............ 3 methadone hcl soln 5 mg/5ml .............. 3 methadone hcl tab 10 mg ................... 3 methadone hcl tab 5 mg ..................... 3 methazolamide tab 25 mg ................. 35 methazolamide tab 50 mg ................. 35 methenamine hippurate tab 1 gm ........ 7 methimazole tab 10 mg .................... 69 methimazole tab 5 mg ...................... 69 methotrexate sodium for inj 1 gm ...... 19 methotrexate sodium inj 25 mg/ml .... 19 methotrexate sodium inj pf 25 mg/ml . 19 methotrexate sodium tab 2.5 mg (base equiv) ............................................. 82 methyclothiazide tab 5 mg ................ 35 methylergonovine maleate tab 0.2 mg 67 methylphenidate hcl soln 10 mg/5ml .. 54 methylphenidate hcl soln 5 mg/5ml .... 54 methylphenidate hcl tab 10 mg .......... 54 methylphenidate hcl tab 20 mg .......... 54 methylphenidate hcl tab 5 mg............ 54 methylphenidate hcl tab cr 10 mg ...... 54 methylphenidate hcl tab cr 20 mg ...... 54 methylprednisolone acetate inj susp 40 mg/ml ............................................ 66 methylprednisolone acetate inj susp 80 mg/ml ............................................ 66 methylprednisolone sodium succinate for inj 1000 mg ..................................... 66 methylprednisolone sodium succinate for inj 125 mg ...................................... 66 129 methylprednisolone sodium succinate for inj 40 mg .........................................66 methylprednisolone tab 16 mg ...........66 methylprednisolone tab 32 mg ...........66 methylprednisolone tab 4 mg .............66 methylprednisolone tab 4 mg dose pack ......................................................66 methylprednisolone tab 8 mg .............66 metipranolol ophth soln 0.3% .............91 metoclopramide hcl inj 5 mg/ml .........72 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) ........................................72 metoclopramide hcl tab 10 mg ...........72 metoclopramide hcl tab 5 mg .............72 metolazone tab 10 mg .......................35 metolazone tab 2.5 mg ......................35 metolazone tab 5 mg ........................35 metoprolol & hydrochlorothiazide tab 100-25 mg .......................................31 metoprolol & hydrochlorothiazide tab 100-50 mg .......................................31 metoprolol & hydrochlorothiazide tab 50-25 mg ........................................31 metoprolol succinate tab sr 24hr 100 mg ......................................................31 metoprolol succinate tab sr 24hr 200 mg ......................................................31 metoprolol succinate tab sr 24hr 25 mg ......................................................31 metoprolol succinate tab sr 24hr 50 mg ......................................................31 metoprolol tartrate inj 1 mg/ml ..........31 metoprolol tartrate tab 100 mg ..........32 metoprolol tartrate tab 25 mg ............31 metoprolol tartrate tab 50 mg ............31 metronidazole cream 0.75% ............ 102 metronidazole gel 0.75% ................. 102 metronidazole in nacl 0.79% iv soln 500 mg/100ml ......................................... 7 metronidazole lotion 0.75% ............. 102 metronidazole tab 250 mg .................. 7 metronidazole tab 500 mg .................. 7 metronidazole vaginal gel 0.75% ........78 mexiletine hcl cap 150 mg .................28 mexiletine hcl cap 200 mg .................28 mexiletine hcl cap 250 mg .................28 MG SO4/D5W INJ 10MG/ML ...............86 MG SO4/D5W INJ 20MG/ML ...............86 MIACALCIN INJ 200/ML ..................... 67 mi-acid chw ..................................... 70 mi-acid sus...................................... 70 mi-acid sus max st ........................... 70 miconazole 3 kit combinat ................. 78 miconazole 3 kit combo pk ................ 78 miconazole 7 cre 2% ........................ 79 miconazole 7 cre tube/kit .................. 79 miconazole 7 sup 100mg................... 79 miconazole nitrate cream 2% ............ 98 miconazole nitrate vaginal cream 2% . 79 miconazole nitrate vaginal suppos 100 mg ...................................................... 79 miconazorb pow af 2% ..................... 98 micro guard pow 2% ........................ 98 microgestin tab 1.5/30 ..................... 63 microgestin tab 1/20 ........................ 63 microgestin tab fe 1/20 ..................... 63 microgestin tab fe1.5/30 ................... 63 midodrine hcl tab 10 mg ................... 36 midodrine hcl tab 2.5 mg .................. 36 midodrine hcl tab 5 mg ..................... 36 milk of magn sus.............................. 74 milk of magn sus 1200/15 ................. 75 milk of magn sus 400/5ml ................. 75 milk of magn sus frsh mnt ................. 75 milk of magn sus mint ...................... 75 minitran dis 0.1mg/hr ....................... 36 minitran dis 0.2mg/hr ....................... 37 minitran dis 0.4mg/hr ....................... 37 minitran dis 0.6mg/hr ....................... 37 minocycline hcl cap 100 mg ............... 17 minocycline hcl cap 50 mg ................ 17 minocycline hcl cap 75 mg ................ 17 minoxidil tab 10 mg.......................... 36 minoxidil tab 2.5 mg......................... 36 mintox plus chw ............................... 71 mintox sus ...................................... 71 mintox sus max st ............................ 71 mirtazapine orally disintegrating tab 15 mg ................................................. 46 mirtazapine orally disintegrating tab 30 mg ................................................. 46 mirtazapine orally disintegrating tab 45 mg ................................................. 46 mirtazapine tab 15 mg ...................... 46 mirtazapine tab 30 mg ...................... 46 mirtazapine tab 45 mg ...................... 46 130 mirtazapine tab 7.5 mg .....................46 misoprostol tab 100 mcg ...................76 misoprostol tab 200 mcg ...................76 mitomycin for iv soln 20 mg ...............19 mitomycin for iv soln 40 mg ...............19 mitomycin for iv soln 5 mg .................19 mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) ............................................23 mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) ........................................23 mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) ............................................23 mitrazol pow 2% ..............................98 M-M-R II INJ ....................................85 moderiba pak 1000/day .....................11 moderiba pak 1200/day .....................12 moderiba pak 600/day ......................11 moderiba pak 800/day ......................11 moexipril hcl tab 15 mg .....................26 moexipril hcl tab 7.5 mg ....................26 moexipril-hydrochlorothiazide tab 15-12.5 mg ......................................25 moexipril-hydrochlorothiazide tab 15-25 mg ..................................................25 moexipril-hydrochlorothiazide tab 7.5-12.5 mg .....................................25 mometasone furoate cream 0.1% ..... 100 mometasone furoate oint 0.1% ........ 101 mometasone furoate solution 0.1% (lotion) .......................................... 101 MONONESSA TAB .............................63 montelukast sodium chew tab 4 mg (base equiv) .............................................94 montelukast sodium chew tab 5 mg (base equiv) .............................................94 montelukast sodium oral granules packet 4 mg (base equiv) ............................94 montelukast sodium tab 10 mg (base equiv) .............................................94 MORPHINE SUL INJ 2MG/ML ................ 3 MORPHINE SUL INJ 4MG/ML ................ 4 MORPHINE SUL INJ 8MG/ML ................ 4 morphine sulfate beads cap sr 24hr 120 mg ................................................... 4 morphine sulfate beads cap sr 24hr 30 mg ....................................................... 4 morphine sulfate beads cap sr 24hr 45 mg ....................................................... 4 morphine sulfate beads cap sr 24hr 60 mg ........................................................ 4 morphine sulfate beads cap sr 24hr 75 mg ........................................................ 4 morphine sulfate beads cap sr 24hr 90 mg ........................................................ 4 morphine sulfate cap sr 24hr 10 mg ..... 4 morphine sulfate cap sr 24hr 100 mg ... 4 morphine sulfate cap sr 24hr 20 mg ..... 4 morphine sulfate cap sr 24hr 30 mg ..... 4 morphine sulfate cap sr 24hr 50 mg ..... 4 morphine sulfate cap sr 24hr 60 mg ..... 4 morphine sulfate cap sr 24hr 80 mg ..... 4 morphine sulfate inj pf 0.5 mg/ml ........ 4 morphine sulfate inj pf 1 mg/ml ........... 4 MORPHINE SULFATE IV SOLN 1 MG/ML . 4 MORPHINE SULFATE IV SOLN PF 10 MG/ML .............................................. 4 MORPHINE SULFATE IV SOLN PF 15 MG/ML .............................................. 4 MORPHINE SULFATE ORAL SOLN 10 MG/5ML ............................................ 4 MORPHINE SULFATE ORAL SOLN 100 MG/5ML (20 MG/ML) .......................... 4 MORPHINE SULFATE ORAL SOLN 20 MG/5ML ............................................ 4 MORPHINE SULFATE TAB 15 MG .......... 4 MORPHINE SULFATE TAB 30 MG .......... 4 morphine sulfate tab cr 100 mg ........... 4 morphine sulfate tab cr 15 mg ............. 4 morphine sulfate tab cr 200 mg ........... 4 morphine sulfate tab cr 30 mg ............. 4 morphine sulfate tab cr 60 mg ............. 4 motion sick tab 25mg ....................... 72 MOVANTIK TAB 12.5MG .................... 76 MOVANTIK TAB 25MG ....................... 76 MOVIPREP SOL ................................ 75 MOXEZA SOL 0.5% .......................... 90 MOZOBIL INJ ................................... 80 MULTAQ TAB 400MG......................... 28 mupirocin oint 2% ............................ 97 MURO 128 SOL 2% OP ...................... 92 MUSTARGEN INJ 10MG ..................... 18 my way tab 1.5mg ........................... 63 MYCAMINE INJ 100MG ........................ 8 MYCAMINE INJ 50MG .......................... 8 mycophenolate mofetil cap 250 mg .... 84 mycophenolate mofetil for oral susp 200 131 mg/ml .............................................84 mycophenolate mofetil tab 500 mg .....84 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)..................84 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)..................84 myorisan cap 10mg...........................97 myorisan cap 20mg...........................97 myorisan cap 40mg...........................97 MYOZYME INJ 50MG ..........................64 MYRBETRIQ TAB 25MG ......................78 MYRBETRIQ TAB 50MG ......................78 myzilra tab.......................................63 N nabumetone tab 500 mg..................... 2 nabumetone tab 750 mg..................... 2 nadolol tab 20 mg .............................32 nadolol tab 40 mg .............................32 nadolol tab 80 mg .............................32 nafcillin sodium for inj 1 gm ...............17 nafcillin sodium for inj 10 gm .............17 nafcillin sodium for inj 2 gm ...............17 nafcillin sodium for iv soln 1 gm .........17 nafcillin sodium for iv soln 2 gm .........17 NAGLAZYME INJ 1MG/ML ...................64 naloxone hcl inj 0.4 mg/ml.................57 naloxone hcl inj 1 mg/ml ...................57 naltrexone hcl tab 50 mg ...................57 NAMENDA SOL 10MG/5ML .................43 NAMENDA TAB 10MG ........................43 NAMENDA TAB 5MG ..........................43 NAMENDA XR CAP 14MG ....................43 NAMENDA XR CAP 21MG ....................43 NAMENDA XR CAP 28MG ....................43 NAMENDA XR CAP 7MG .....................43 NAMENDA XR CAP TITRATIO ..............43 NAMZARIC CAP 14-10MG ...................43 NAMZARIC CAP 28-10MG ...................43 naphazoline hcl ophth soln 0.1% ........92 naproxen dr tab 375mg ...................... 2 naproxen dr tab 500mg ...................... 2 naproxen sodium tab 275 mg .............. 2 naproxen sodium tab 550 mg .............. 2 naproxen susp 125 mg/5ml ................. 2 naproxen tab 250 mg ......................... 2 naproxen tab 375 mg ......................... 2 naproxen tab 500 mg ......................... 2 naratriptan hcl tab 1 mg (base equiv)..55 naratriptan hcl tab 2.5 mg (base equiv) ...................................................... 55 nasal moist spr 0.65% ...................... 95 nasal saline spr 0.65%...................... 95 NASONEX SPR 50MCG/AC ................. 95 nat fiber pow 48.57% ....................... 75 nat fiber pow therapy ....................... 75 NATACYN SUS 5% OP ....................... 90 nateglinide tab 120 mg ..................... 60 nateglinide tab 60 mg ....................... 60 natural bal sol 0.4% ......................... 92 natures tear sol 0.4% ....................... 92 naturl fiber pow 28.3% ..................... 75 naturl fiber pow therapy .................... 75 NEBUPENT INH 300MG ....................... 7 necon tab 0.5/35 ............................. 63 necon tab 1/35 ................................ 63 NECON TAB 1/50-28 ......................... 63 necon tab 10/11-28 .......................... 63 NECON TAB 7/7/7 ............................ 63 nefazodone hcl tab 100 mg ............... 46 nefazodone hcl tab 150 mg ............... 46 nefazodone hcl tab 200 mg ............... 46 nefazodone hcl tab 250 mg ............... 46 nefazodone hcl tab 50 mg ................. 46 neomycin sulfate tab 500 mg ............... 5 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin ..... 90 neomycin-bacitracin-polymyxin oint ... 97 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml ....... 90 neomycin-polymyxin-dexamethasone ophth oint 0.1% ............................... 89 neomycin-polymyxin-dexamethasone ophth susp 0.1% .............................. 89 neomycin-polymyxin-hc ophth susp .... 89 neomycin-polymyxin-hc otic soln 1% 103 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ............... 103 NEORAL CAP 100MG ......................... 84 NEORAL CAP 25MG ........................... 84 NEORAL SOL 100MG/ML .................... 84 NEPHRAMINE INJ 5.4% ..................... 87 NEUMEGA INJ 5MG ........................... 80 NEUPOGEN INJ 300/0.5 .................... 80 NEUPOGEN INJ 300MCG .................... 80 NEUPOGEN INJ 480/0.8 .................... 80 NEUPOGEN INJ 480MCG .................... 80 132 NEUPRO DIS 1MG/24HR ....................48 NEUPRO DIS 2MG/24HR ....................48 NEUPRO DIS 3MG/24HR ....................48 NEUPRO DIS 4MG/24HR ....................48 NEUPRO DIS 6MG/24HR ....................48 NEUPRO DIS 8MG/24HR ....................48 NEVANAC SUS 0.1% .........................91 NEVIRAPINE SUSP 50 MG/5ML ............ 9 nevirapine tab 200 mg ....................... 9 nevirapine tab sr 24hr 400 mg ............ 9 NEXAVAR TAB 200MG........................22 NEXIUM CAP 20MG ...........................77 NEXIUM CAP 40MG ...........................77 NEXIUM GRA 10MG DR ......................77 NEXIUM GRA 2.5MG DR .....................77 NEXIUM GRA 20MG DR ......................77 NEXIUM GRA 40MG DR ......................77 NEXIUM GRA 5MG DR ........................77 next choice tab 1.5mg .......................63 niacin tab cr 1000 mg (antihyperlipidemic) ..........................30 niacin tab cr 500 mg (antihyperlipidemic) ......................................................30 niacin tab cr 750 mg (antihyperlipidemic) ......................................................30 niacor tab 500mg .............................30 nicardipine hcl cap 20 mg ..................33 nicardipine hcl cap 30 mg ..................33 nicorelief gum 2mg mint ....................58 nicorelief gum 2mg orig .....................58 nicorelief gum 4mg mint ....................58 nicorelief gum 4mg orig .....................58 nicotine polacrilex gum 2 mg ..............58 nicotine polacrilex gum 4 mg ..............58 nicotine td patch 24hr 14 mg/24hr ......58 NICOTINE TD PATCH 24HR 14 MG/24HR ......................................................58 nicotine td patch 24hr 21 mg/24hr ......58 NICOTINE TD PATCH 24HR 21 MG/24HR ......................................................58 nicotine td patch 24hr 7 mg/24hr .......58 NICOTINE TD PATCH 24HR 7 MG/24HR58 NICOTROL INH .................................58 NICOTROL NS SPR 10MG/ML ..............58 nifedical xl tab 30mg .........................33 nifedical xl tab 60mg .........................33 nifedipine tab sr 24hr 30 mg ..............33 nifedipine tab sr 24hr 60 mg ..............33 nifedipine tab sr 24hr 90 mg.............. 33 nifedipine tab sr 24hr osmotic release 30 mg ................................................. 33 nifedipine tab sr 24hr osmotic release 60 mg ................................................. 33 nifedipine tab sr 24hr osmotic release 90 mg ................................................. 33 nikki tab 3-0.02mg ........................... 63 NILANDRON TAB 150MG ................... 21 nimodipine cap 30 mg ...................... 34 NIPENT INJ 10MG............................. 19 nitro-bid oin 2% ............................... 37 NITRO-DUR DIS 0.3MG/HR ................ 37 NITRO-DUR DIS 0.8MG/HR ................ 37 nitrofurantoin macrocrystalline cap 100 mg ................................................... 7 nitrofurantoin macrocrystalline cap 50 mg ........................................................ 7 nitrofurantoin monohydrate macrocrystalline cap 100 mg ............... 7 nitroglycerin td patch 24hr 0.1 mg/hr . 37 nitroglycerin td patch 24hr 0.2 mg/hr . 37 nitroglycerin td patch 24hr 0.4 mg/hr . 37 nitroglycerin td patch 24hr 0.6 mg/hr . 37 NITROLINGUAL SPR PUMPSPRA ......... 37 NITROSTAT SUB 0.3MG .................... 37 NITROSTAT SUB 0.4MG .................... 37 NITROSTAT SUB 0.6MG .................... 37 NORDITROPIN INJ 10/1.5ML.............. 67 NORDITROPIN INJ 15/1.5ML.............. 67 NORDITROPIN INJ 30/3ML ................ 67 NORDITROPIN INJ 5/1.5ML ............... 67 norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr ............................. 63 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg ............................. 63 norethindrone acetate tab 5 mg ......... 68 norethindrone tab 0.35 mg ................ 63 NORETHINDRONE TAB 0.35 MG ......... 63 NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG ............. 63 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg ... 63 norlyroc tab 0.35mg ......................... 63 normosol -m inj /d5w ....................... 89 NORMOSOL -R INJ /D5W ................... 89 NORMOSOL-R INJ PH 7.4 .................. 89 NORPACE CAP 100MG CR .................. 28 133 NORPACE CAP 150MG CR ...................28 nortrel tab 0.5/35 .............................63 nortrel tab 1/35 ................................63 nortrel tab 7/7/7 ...............................63 nortriptyline hcl cap 10 mg ................46 nortriptyline hcl cap 25 mg ................46 nortriptyline hcl cap 50 mg ................46 nortriptyline hcl cap 75 mg ................46 nortriptyline hcl soln 10 mg/5ml .........46 NORVIR CAP 100MG ........................... 9 NORVIR SOL 80MG/ML ....................... 9 NORVIR TAB 100MG ........................... 9 NOVOLIN INJ 70/30 ..........................59 NOVOLIN N INJ U-100 .......................59 NOVOLIN R INJ U-100 .......................59 NOVOLOG INJ 100/ML .......................59 NOVOLOG INJ FLEXPEN .....................59 NOVOLOG INJ PENFILL ......................59 NOVOLOG MIX INJ 70/30 ...................59 NOVOLOG MIX INJ FLEXPEN ...............59 NOXAFIL SUS 40MG/ML ...................... 8 NOXAFIL TAB 100MG.......................... 8 NUEDEXTA CAP 20-10MG ...................56 NULOJIX INJ 250MG ..........................84 NULYTELY SOL FLAV PKS ...................75 NUPERCAINAL OIN 1% .................... 101 NUTRISOURCE POW FIBER .................75 NUVARING MIS.................................63 NUVIGIL TAB 150MG .........................57 NUVIGIL TAB 200MG .........................57 NUVIGIL TAB 250MG .........................57 NUVIGIL TAB 50MG ...........................57 nyamyc pow 100000 .........................98 NYMALIZE SOL 60/20ML ....................34 nystatin cream 100000 unit/gm ..........98 nystatin oint 100000 unit/gm .............98 nystatin susp 100000 unit/ml ........... 103 nystatin tab 500000 unit..................... 8 nystatin topical powder ......................98 nystop pow 100000...........................98 O OCTAGAM INJ 10GM..........................83 OCTAGAM INJ 1GM ...........................83 OCTAGAM INJ 2.5GM.........................83 OCTAGAM INJ 25GM..........................83 OCTAGAM INJ 2GM/20ML ...................83 OCTAGAM INJ 5GM ...........................83 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) ........................................... 67 octreotide acetate inj 1000 mcg/ml (1 mg/ml) ........................................... 67 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) ........................................... 67 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) ........................................... 67 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) ........................................... 67 ofloxacin ophth soln 0.3% ................. 90 ofloxacin otic soln 0.3% .................. 103 olanzapine for im inj 10 mg ............... 51 olanzapine orally disintegrating tab 10 mg ...................................................... 51 olanzapine orally disintegrating tab 15 mg ...................................................... 51 olanzapine orally disintegrating tab 20 mg ...................................................... 51 olanzapine orally disintegrating tab 5 mg ...................................................... 51 olanzapine tab 10 mg ....................... 51 olanzapine tab 15 mg ....................... 52 olanzapine tab 2.5 mg ...................... 51 olanzapine tab 20 mg ....................... 52 olanzapine tab 5 mg ......................... 51 olanzapine tab 7.5 mg ...................... 51 olopatadine hcl nasal soln 0.6% ......... 93 OLYSIO CAP 150MG.......................... 12 omega-3-acid ethyl esters cap 1 gm ... 30 omeprazole cap delayed release 10 mg77 omeprazole cap delayed release 20 mg77 omeprazole cap delayed release 40 mg77 ondansetron hcl inj 4 mg/2ml (2 mg/ml) ...................................................... 72 ondansetron hcl inj 40 mg/20ml (2 mg/ml) ........................................... 72 ondansetron hcl oral soln 4 mg/5ml .... 72 ondansetron hcl tab 24 mg ................ 72 ondansetron hcl tab 4 mg.................. 72 ondansetron hcl tab 8 mg.................. 72 ondansetron orally disintegrating tab 4 mg ................................................. 72 ondansetron orally disintegrating tab 8 mg ................................................. 72 ONFI SUS 2.5MG/ML......................... 41 ONFI TAB 10MG ............................... 41 ONFI TAB 20MG ............................... 41 operand scrb sol 7.5% .................... 102 134 optics mini dro .................................92 oral electrolyte solution .....................86 oral saline sol laxative .......................75 oralyte sol ........................................86 ORAP TAB 1MG .................................52 ORAP TAB 2MG .................................52 ORFADIN CAP 10MG ..........................65 ORFADIN CAP 2MG ...........................64 ORFADIN CAP 5MG ...........................64 ORKAMBI TAB 200-125 .....................95 orsythia tab .....................................63 oxacillin sodium for inj 1 gm ..............17 oxacillin sodium for inj 10 gm .............17 oxacillin sodium for inj 2 gm ..............17 oxaliplatin for iv inj 100 mg................23 oxaliplatin for iv inj 50 mg .................23 oxaliplatin iv soln 100 mg/20ml ..........23 oxaliplatin iv soln 50 mg/10ml ............23 oxandrolone tab 10 mg ......................58 oxandrolone tab 2.5 mg.....................58 oxcarbazepine susp 300 mg/5ml (60 mg/ml) ............................................41 oxcarbazepine tab 150 mg .................41 oxcarbazepine tab 300 mg .................41 oxcarbazepine tab 600 mg .................41 oxybutynin chloride syrup 5 mg/5ml ...78 oxybutynin chloride tab 5 mg .............78 oxybutynin chloride tab sr 24hr 10 mg 78 oxybutynin chloride tab sr 24hr 15 mg 78 oxybutynin chloride tab sr 24hr 5 mg ..78 oxycodone hcl cap 5 mg ..................... 4 OXYCODONE HCL CONC 100 MG/5ML (20 MG/ML) ............................................ 4 oxycodone hcl soln 5 mg/5ml .............. 4 oxycodone hcl tab 10 mg .................... 4 oxycodone hcl tab 15 mg .................... 4 oxycodone hcl tab 20 mg .................... 4 oxycodone hcl tab 30 mg .................... 4 oxycodone hcl tab 5 mg ...................... 4 oxycodone w/ acetaminophen tab 10-325 mg ................................................... 5 oxycodone w/ acetaminophen tab 2.5-325 mg ................................................... 4 oxycodone w/ acetaminophen tab 5-325 mg ................................................... 5 oxycodone w/ acetaminophen tab 7.5-325 mg ................................................... 5 P pacerone tab 100mg......................... 28 pacerone tab 200mg......................... 28 pacerone tab 400mg......................... 28 paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) ........................................... 20 paclitaxel iv conc 150 mg/25ml (6 mg/ml) ...................................................... 20 paclitaxel iv conc 30 mg/5ml (6 mg/ml) ...................................................... 20 paclitaxel iv conc 300 mg/50ml (6 mg/ml) ...................................................... 20 pamidronate disodium iv soln 3 mg/ml 61 pamidronate disodium iv soln 9 mg/ml 61 pamidronate inj 6mg/ml.................... 61 PANRETIN GEL 0.1% ...................... 102 pantoprazole sodium ec tab 20 mg (base equiv) ............................................. 77 pantoprazole sodium ec tab 40 mg (base equiv) ............................................. 77 paricalcitol cap 1 mcg ....................... 89 paricalcitol cap 2 mcg ....................... 89 paricalcitol cap 4 mcg ....................... 89 paromomycin sulfate cap 250 mg ......... 5 paroxetine hcl tab 10 mg .................. 46 paroxetine hcl tab 20 mg .................. 46 paroxetine hcl tab 30 mg .................. 46 paroxetine hcl tab 40 mg .................. 46 paser gra 4gm ................................. 11 PATADAY SOL 0.2% ......................... 91 PATANOL SOL 0.1% OP..................... 91 PAXIL SUS 10MG/5ML ....................... 46 PAZEO DRO 0.7% ............................ 91 ped elctrlyt sol fruit .......................... 86 ped elctrlyt sol unflavrd .................... 86 pedi-boro pow soak pak .................. 102 PEDVAX HIB INJ ............................... 85 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm .................................... 75 PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 240 GM .............. 75 peg 3350-kcl-sod bicarb-nacl for soln 420 gm ................................................. 75 PEGANONE TAB 250MG ..................... 41 PEG-INTRON KIT 120 RP ................... 83 PEGINTRON KIT 120MCG .................. 83 PEG-INTRON KIT 150 RP ................... 83 PEGINTRON KIT 150MCG .................. 83 135 PEG-INTRON KIT 50MCG ...................83 PEG-INTRON KIT 50MCG RP ...............83 PEGINTRON KIT 80MCG .....................83 PEG-INTRON KIT 80MCG RP ...............83 pen g proc inj 600000 .......................17 PENICILL GK/ INJ DEX 2MU ................17 PENICILL GK/ INJ DEX 3MU ................17 penicillin g potassium for inj 20000000 unit .................................................17 penicillin g potassium for inj 5000000 unit ......................................................17 penicillin g sodium for inj 5000000 unit ......................................................17 penicillin v potassium for soln 125 mg/5ml ......................................................17 penicillin v potassium for soln 250 mg/5ml ......................................................17 penicillin v potassium tab 250 mg .......17 penicillin v potassium tab 500 mg .......17 PENTAM 300 INJ 300MG ..................... 7 PENTASA CAP 250MG CR ...................73 PENTASA CAP 500MG CR ...................73 pentoxifylline tab cr 400 mg ...............81 peptic relf chw 262mg .......................71 PERFOROMIST NEB 20MCG ................94 peri-colace tab 8.6-50mg ...................75 periguard oin .................................. 102 perindopril erbumine tab 2 mg ...........26 perindopril erbumine tab 4 mg ...........26 perindopril erbumine tab 8 mg ...........26 periogard sol 0.12% ........................ 103 permethrin cream 5% ..................... 102 permethrin lotion 1% ...................... 102 perphenazine tab 16 mg ....................52 perphenazine tab 2 mg ......................52 perphenazine tab 4 mg ......................52 perphenazine tab 8 mg ......................52 phenelzine sulfate tab 15 mg..............46 PHENOBARB INJ 65MG/ML .................41 phenobarbital elixir 20 mg/5ml ...........41 phenobarbital sodium inj 130 mg/ml ...41 phenobarbital tab 100 mg ..................42 phenobarbital tab 15 mg ....................41 phenobarbital tab 16.2 mg .................41 phenobarbital tab 30 mg ....................41 phenobarbital tab 32.4 mg .................41 phenobarbital tab 60 mg....................41 phenobarbital tab 64.8 mg .................41 phenobarbital tab 97.2 mg ................ 41 phenytek cap 200mg ........................ 42 phenytek cap 300mg ........................ 42 phenytoin chew tab 50 mg ................ 42 phenytoin sodium extended cap 100 mg ...................................................... 42 phenytoin sodium extended cap 200 mg ...................................................... 42 phenytoin sodium extended cap 300 mg ...................................................... 42 phenytoin sodium inj 50 mg/ml ......... 42 phenytoin susp 125 mg/5ml .............. 42 philith tab 0.4-35 ............................. 63 PHOSLYRA SOL ................................ 68 PHOSPHOLINE SOL 0.125%OP ........... 91 PILOCARPINE HCL OPHTH SOLN 1% ... 91 PILOCARPINE HCL OPHTH SOLN 2% ... 92 PILOCARPINE HCL OPHTH SOLN 4% ... 92 pilocarpine hcl tab 5 mg .................. 103 pilocarpine hcl tab 7.5 mg ............... 103 pimtrea tab ..................................... 63 pindolol tab 10 mg ........................... 32 pindolol tab 5 mg ............................. 32 pink bismuth chw 262mg .................. 71 pioglitazone hcl tab 15 mg (base equiv) ...................................................... 60 pioglitazone hcl tab 30 mg (base equiv) ...................................................... 60 pioglitazone hcl tab 45 mg (base equiv) ...................................................... 60 piperacillin sodium-tazobactam sodium for inj 2-0.25 gm ............................. 17 piperacillin sodium-tazobactam sodium for inj 3-0.375 gm ............................ 17 piperacillin sodium-tazobactam sodium for inj 36-4.5 gm ............................. 17 piperacillin sodium-tazobactam sodium for inj 4-0.5 gm ............................... 17 pirmella tab 1/35 ............................. 63 piroxicam cap 10 mg .......................... 2 piroxicam cap 20 mg .......................... 2 PLASMA-LYTE INJ -148 ..................... 89 PLASMA-LYTE INJ 56/D5W ................ 89 PLASMA-LYTE INJ -A ......................... 89 podofilox soln 0.5% ........................ 102 polyethylene glycol 3350 oral packet .. 75 polyethylene glycol 3350 oral powder . 75 polymyxin b-trimethoprim ophth soln 136 10000 unit/ml-0.1% .........................90 POMALYST CAP 1MG .........................23 POMALYST CAP 2MG .........................23 POMALYST CAP 3MG .........................23 POMALYST CAP 4MG .........................23 portia-28 tab ....................................63 POTASSIUM CHLORIDE 20 MEQ/L (0.15%) IN DEXTROSE 5% INJ ...........89 POTASSIUM CHLORIDE 40 MEQ/L (0.3%) IN DEXTROSE 5% INJ .......................89 potassium chloride cap cr 10 meq .......86 potassium chloride cap cr 8 meq .........86 POTASSIUM CHLORIDE INJ 10 MEQ/100 ML ..................................................89 potassium chloride inj 10 meq/50 ml ...89 potassium chloride inj 2 meq/ml .........89 POTASSIUM CHLORIDE INJ 20 MEQ/100 ML ..................................................89 potassium chloride inj 20 meq/50 ml ...89 potassium chloride inj 40 meq/100 ml .89 potassium chloride microencapsulated crys cr tab 10 meq ............................86 potassium chloride microencapsulated crys cr tab 20 meq ............................86 potassium chloride oral soln 10% (20 meq/15ml).......................................86 potassium chloride oral soln 20% (40 meq/15ml).......................................86 POTASSIUM CHLORIDE TAB CR 10 MEQ ......................................................86 POTASSIUM CHLORIDE TAB CR 20 MEQ (1500 MG) .......................................86 potassium chloride tab cr 8 meq (600 mg) ......................................................86 POTASSIUM CITRATE TAB CR 10 MEQ (1080 MG) .......................................78 POTASSIUM CITRATE TAB CR 5 MEQ (540 MG) ................................................78 POTIGA TAB 200MG ..........................42 POTIGA TAB 300MG ..........................42 POTIGA TAB 400MG ..........................42 POTIGA TAB 50MG ............................42 povidone-iod sol 10% ...................... 102 povidone-iodine oint 10% ................ 102 povidone-iodine soln 10% ................ 102 povidone-iodine swabs 10% ............. 102 PRADAXA CAP 150MG ........................80 PRADAXA CAP 75MG .........................80 pramipexole dihydrochloride tab 0.125 mg ................................................. 49 pramipexole dihydrochloride tab 0.25 mg ...................................................... 48 pramipexole dihydrochloride tab 0.5 mg ...................................................... 48 pramipexole dihydrochloride tab 0.75 mg ...................................................... 49 pramipexole dihydrochloride tab 1 mg 49 pramipexole dihydrochloride tab 1.5 mg ...................................................... 49 pravastatin sodium tab 10 mg ........... 29 pravastatin sodium tab 20 mg ........... 29 pravastatin sodium tab 40 mg ........... 29 pravastatin sodium tab 80 mg ........... 29 prazosin hcl cap 1 mg ....................... 26 prazosin hcl cap 2 mg ....................... 26 prazosin hcl cap 5 mg ....................... 26 pred sod pho sol 1% op .................... 91 PREDNISOLONE ACETATE OPHTH SUSP 1% ................................................. 91 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) .................. 66 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) ........................ 66 prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) ........................ 66 prednisolone syrup 15 mg/5ml (usp solution equivalent) .......................... 66 prednisone con 5mg/ml .................... 66 prednisone oral soln 5 mg/5ml ........... 66 prednisone tab 1 mg......................... 66 prednisone tab 10 mg ....................... 67 prednisone tab 10 mg dose pack ........ 67 prednisone tab 2.5 mg ...................... 66 prednisone tab 20 mg ....................... 67 prednisone tab 5 mg......................... 66 prednisone tab 5 mg dose pack .......... 67 prednisone tab 50 mg ....................... 67 PREMARIN VAG CRE 0.625MG ............ 65 premasol sol 10% ............................ 87 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) ................................. 89 prep h hc cre 1% ........................... 101 prevalite pow 4gm............................ 30 previfem tab .................................... 63 PREZCOBIX TAB 800-150 .................. 10 PREZISTA SUS 100MG/ML ................... 9 137 PREZISTA TAB 150MG ........................ 9 PREZISTA TAB 600MG ........................ 9 PREZISTA TAB 75MG .......................... 9 PREZISTA TAB 800MG ........................ 9 PRIFTIN TAB 150MG ..........................11 PRIMAQUINE TAB 26.3MG ................... 8 primidone tab 250 mg .......................42 primidone tab 50 mg .........................42 PRISTIQ TAB 100MG .........................47 PRISTIQ TAB 25MG ...........................47 PRISTIQ TAB 50MG ...........................47 PRIVIGEN INJ 10GRAMS ....................83 PRIVIGEN INJ 20GRAMS ....................83 PRIVIGEN INJ 40GRAMS ....................83 PRIVIGEN INJ 5 GRAMS .....................83 PROAIR HFA AER ..............................94 probenecid tab 500 mg ....................... 1 PROCALAMINE INJ 3%.......................87 prochlorperazine edisylate inj 5 mg/ml 72 prochlorperazine maleate tab 10 mg (base equivalent) ......................................72 prochlorperazine maleate tab 5 mg (base equivalent) ......................................72 prochlorperazine suppos 25 mg ..........72 PROCRIT INJ 10000/ML .....................81 PROCRIT INJ 2000/ML .......................81 PROCRIT INJ 20000/ML .....................81 PROCRIT INJ 3000/ML .......................81 PROCRIT INJ 4000/ML .......................81 PROCRIT INJ 40000/ML .....................81 procto-pak cre 1% ............................98 proctozone cre -hc 2.5%....................98 PROGLYCEM SUS 50MG/ML ................67 PROGRAF CAP 0.5MG ........................84 PROGRAF CAP 1MG ...........................84 PROGRAF CAP 5MG ...........................84 PROLASTIN-C INJ 1000MG .................95 PROLENSA SOL 0.07% ......................92 PROLEUKIN INJ 22MU........................20 PROLIA SOL 60MG/ML .......................68 PROMACTA TAB 12.5MG ....................81 PROMACTA TAB 25MG .......................81 PROMACTA TAB 50MG .......................81 PROMACTA TAB 75MG .......................81 promethazine hcl inj 25 mg/ml ...........72 promethazine hcl inj 50 mg/ml ...........72 propafenone hcl cap sr 12hr 225 mg ...28 propafenone hcl cap sr 12hr 325 mg ...29 propafenone hcl cap sr 12hr 425 mg... 29 propafenone hcl tab 150 mg .............. 29 propafenone hcl tab 225 mg .............. 29 propafenone hcl tab 300 mg .............. 29 proparacaine hcl ophth soln 0.5% ...... 92 propranolol & hydrochlorothiazide tab 40-25 mg ........................................ 31 propranolol & hydrochlorothiazide tab 80-25 mg ........................................ 31 propranolol hcl cap sr 24hr 120 mg .... 32 propranolol hcl cap sr 24hr 160 mg .... 32 propranolol hcl cap sr 24hr 60 mg ...... 32 propranolol hcl cap sr 24hr 80 mg ...... 32 propranolol hcl inj 1 mg/ml ............... 32 propranolol hcl oral soln 20 mg/5ml ... 32 propranolol hcl oral soln 40 mg/5ml ... 32 propranolol hcl tab 10 mg ................. 32 propranolol hcl tab 20 mg ................. 32 propranolol hcl tab 40 mg ................. 32 propranolol hcl tab 60 mg ................. 32 propranolol hcl tab 80 mg ................. 32 propylthiouracil tab 50 mg................. 69 PROQUAD INJ .................................. 85 PROSHIELD CRE PLUS .................... 102 PROSHIELD CRE PROTECT ............... 102 PROSOL INJ 20% ............................. 87 protriptyline hcl tab 10 mg ................ 47 protriptyline hcl tab 5 mg .................. 47 PRUDOXIN CRE 5% .......................... 98 PULMOZYME SOL 1MG/ML ................. 95 pure & gentl dro 0.3% ...................... 92 PURIXAN SUS 20MG/ML .................... 19 px iron tab 200mg ............................ 81 pyrazinamide tab 500 mg .................. 11 pyridostigmine bromide tab 60 mg ..... 56 Q QUADRACEL INJ ............................... 85 quasense tab ................................... 63 quetiapine fumarate tab 100 mg ........ 52 quetiapine fumarate tab 200 mg ........ 52 quetiapine fumarate tab 25 mg .......... 52 quetiapine fumarate tab 300 mg ........ 52 quetiapine fumarate tab 400 mg ........ 52 quetiapine fumarate tab 50 mg .......... 52 quinapril hcl tab 10 mg ..................... 26 quinapril hcl tab 20 mg ..................... 26 quinapril hcl tab 40 mg ..................... 26 quinapril hcl tab 5 mg ....................... 26 138 quinapril-hydrochlorothiazide tab 10-12.5 mg ..................................................25 quinapril-hydrochlorothiazide tab 20-12.5 mg ..................................................25 quinapril-hydrochlorothiazide tab 20-25 mg ..................................................25 quinidine gluconate tab cr 324 mg ......29 quinidine sulfate tab 200 mg ..............29 quinidine sulfate tab 300 mg ..............29 quinine sulfate cap 324 mg ................. 8 QVAR AER 40MCG .............................95 QVAR AER 80MCG .............................95 R RABAVERT INJ ..................................85 raloxifene hcl tab 60 mg ....................68 ramipril cap 1.25 mg .........................26 ramipril cap 10 mg ............................26 ramipril cap 2.5 mg ...........................26 ramipril cap 5 mg .............................26 RANEXA TAB 1000MG ........................36 RANEXA TAB 500MG .........................36 ranitidine hcl inj 150 mg/6ml (25 mg/ml) ......................................................73 ranitidine hcl inj 50 mg/2ml (25 mg/ml) ......................................................73 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ..........................................73 ranitidine hcl tab 150 mg ...................73 ranitidine hcl tab 300 mg ...................73 ranitidine hcl tab 75 mg .....................73 RAPAMUNE SOL 1MG/ML....................84 REBETOL SOL 40MG/ML .....................12 reclipsen tab ....................................64 RECOMBIVA HB INJ 10MCG/ML ...........85 RECOMBIVA HB INJ 5MCG/0.5 ............85 RECOMBIVA-HB INJ 40MCG/ML ..........85 REFRESH CELL DRO 1% OP ................92 refresh lacr oin op .............................92 REFRESH LIQU DRO 1% OP ...............92 REGRANEX GEL 0.01% .................... 102 reguloid cap 0.52gm .........................75 reguloid pow 28.3% ..........................75 reguloid pow 48.57% ........................75 reguloid pow 58.6% ..........................75 RELENZA MIS DISKHALE....................12 RELISTOR INJ 12/0.6ML ....................75 RELISTOR INJ 8/0.4ML ......................75 RELISTOR KIT 12/0.6ML ....................75 RELPAX TAB 20MG ........................... 55 RELPAX TAB 40MG ........................... 55 remedy pow antifung ........................ 98 REMICADE INJ 100MG ...................... 82 REMODULIN INJ 10MG/ML ................. 37 REMODULIN INJ 1MG/ML .................. 37 REMODULIN INJ 2.5MG/ML ................ 37 REMODULIN INJ 5MG/ML .................. 37 RENVELA PAK 0.8GM ........................ 68 RENVELA PAK 2.4GM ........................ 68 RENVELA TAB 800MG ....................... 68 repaglinide tab 0.5 mg ...................... 60 repaglinide tab 1 mg......................... 60 repaglinide tab 2 mg......................... 60 RESCRIPTOR TAB 100 MG ................... 9 RESCRIPTOR TAB 200MG .................... 9 RESTASIS EMU 0.05% ...................... 92 retaine cmc sol 0.5% op ................... 92 RETROVIR INJ 10MG/ML ..................... 9 REVATIO SUS 10MG/ML .................... 37 REVLIMID CAP 10MG ........................ 84 REVLIMID CAP 15MG ........................ 84 REVLIMID CAP 2.5MG ....................... 83 REVLIMID CAP 20MG ........................ 84 REVLIMID CAP 25MG ........................ 84 REVLIMID CAP 5MG .......................... 83 REXULTI TAB 0.25MG ....................... 52 REXULTI TAB 0.5MG ......................... 52 REXULTI TAB 1MG ............................ 52 REXULTI TAB 2MG ............................ 52 REXULTI TAB 3MG ............................ 52 REXULTI TAB 4MG ............................ 52 REYATAZ CAP 150MG ......................... 9 REYATAZ CAP 200MG ......................... 9 REYATAZ CAP 300MG ......................... 9 REYATAZ POW 50MG .......................... 9 ribapak pak 1000/day ....................... 12 ribapak pak 1200/day ....................... 12 ribapak pak 600/day......................... 12 ribapak pak 800/day......................... 12 ribasphere cap 200mg ...................... 12 ribasphere tab 200mg....................... 12 ribasphere tab 400mg....................... 12 ribasphere tab 600mg....................... 12 ribavirin cap 200 mg......................... 12 ribavirin tab 200 mg ......................... 12 rifabutin cap 150 mg ........................ 11 rifampin cap 150 mg ........................ 11 139 rifampin cap 300 mg .........................11 rifampin for inj 600 mg ......................11 RIFATER TAB ....................................11 riluzole tab 50 mg .............................56 rimantadine hydrochloride tab 100 mg 12 RINGER'S SOLUTION .........................89 RIOMET SOL ....................................60 RISPERDAL INJ 12.5MG .....................52 RISPERDAL INJ 25MG ........................52 RISPERDAL INJ 37.5MG .....................52 RISPERDAL INJ 50MG ........................52 risperidone orally disintegrating tab 0.25 mg ..................................................52 risperidone orally disintegrating tab 0.5 mg ..................................................52 risperidone orally disintegrating tab 1 mg ......................................................52 risperidone orally disintegrating tab 2 mg ......................................................52 risperidone orally disintegrating tab 3 mg ......................................................52 risperidone orally disintegrating tab 4 mg ......................................................52 risperidone soln 1 mg/ml ...................52 risperidone tab 0.25 mg ....................52 risperidone tab 0.5 mg ......................52 risperidone tab 1 mg .........................53 risperidone tab 2 mg .........................53 risperidone tab 3 mg .........................53 risperidone tab 4 mg .........................53 RITUXAN INJ 500MG .........................20 rivastigmine tartrate cap 1.5 mg .........43 rivastigmine tartrate cap 3 mg ...........43 rivastigmine tartrate cap 4.5 mg .........43 rivastigmine tartrate cap 6 mg ...........43 RIVASTIGMINE TD PATCH 24HR 13.3 MG/24HR .........................................44 RIVASTIGMINE TD PATCH 24HR 4.6 MG/24HR .........................................44 RIVASTIGMINE TD PATCH 24HR 9.5 MG/24HR .........................................44 rizatriptan benzoate orally disintegrating tab 10 mg ........................................55 rizatriptan benzoate orally disintegrating tab 5 mg..........................................55 rizatriptan benzoate tab 10 mg ...........55 rizatriptan benzoate tab 5 mg.............55 ropinirole hydrochloride tab 0.25 mg ...49 ropinirole hydrochloride tab 0.5 mg .... 49 ropinirole hydrochloride tab 1 mg ....... 49 ropinirole hydrochloride tab 2 mg ....... 49 ropinirole hydrochloride tab 3 mg ....... 49 ropinirole hydrochloride tab 4 mg ....... 49 ropinirole hydrochloride tab 5 mg ....... 49 rosadan cre 0.75% ......................... 102 ROTARIX SUS .................................. 85 ROTATEQ SOL.................................. 85 roxicet sol 5-325/5 ............................. 5 ROZEREM TAB 8MG .......................... 55 rulox sus ......................................... 71 S SABRIL POW 500MG ......................... 42 SABRIL TAB 500MG .......................... 42 saline mist spr 0.65% ....................... 95 saline nasal spr 0.65%...................... 95 saline nasal spray 0.65% .................. 95 SANDIMMUNE CAP 100MG................. 84 SANDIMMUNE CAP 25MG .................. 84 SANDIMMUNE SOL 100MG/ML ........... 84 SANDOSTATIN KIT LAR 10MG ............ 68 SANDOSTATIN KIT LAR 20MG ............ 68 SANDOSTATIN KIT LAR 30MG ............ 68 SANTYL OIN 250/GM ...................... 102 SAPHRIS SUB 10MG ......................... 53 SAPHRIS SUB 2.5MG ........................ 53 SAPHRIS SUB 5MG ........................... 53 sb milk magn sus ............................. 75 sb saline spr 0.65% .......................... 95 sb triple oin antibiot ......................... 97 sea soft spr 0.65% ........................... 95 SEA-CLENS LIQ WOUND ................. 102 selegiline hcl cap 5 mg ...................... 49 selegiline hcl tab 5 mg ...................... 49 selenium sulfide lotion 2.5% .............. 99 SELZENTRY TAB 150MG ...................... 9 SELZENTRY TAB 300MG .................... 10 senexon tab 8.6mg .......................... 75 senna lax tab 8.6mg ......................... 75 senna plus tab 8.6-50mg .................. 75 SENNA TAB 8.6MG ........................... 75 senna-lax tab 8.6mg ........................ 75 sennalax-s tab 8.6-50mg .................. 75 sennosides syrup 8.8 mg/5ml ............ 75 sennosides tab 15 mg ....................... 75 sennosides tab 8.6 mg ...................... 75 sennosides-docusate sodium tab 8.6-50 140 mg ..................................................75 SENSIPAR TAB 30MG ........................61 SENSIPAR TAB 60MG ........................61 SENSIPAR TAB 90MG ........................61 SEREVENT DIS AER 50MCG ................94 SEROQUEL XR TAB 150MG .................53 SEROQUEL XR TAB 200MG .................53 SEROQUEL XR TAB 300MG .................53 SEROQUEL XR TAB 400MG .................53 SEROQUEL XR TAB 50MG...................53 sertraline hcl oral conc 20 mg/ml ........47 sertraline hcl tab 100 mg ...................47 sertraline hcl tab 25 mg .....................47 sertraline hcl tab 50 mg .....................47 sharobel tab 0.35mg .........................64 silace liq 10mg/ml.............................75 silace syp 60/15ml ............................75 sildenafil citrate tab 20 mg .................37 SILENOR TAB 3MG ............................55 SILENOR TAB 6MG ............................55 SILVER SULFADIAZINE CREAM 1% .....97 SIMBRINZA SUS 1-0.2%....................92 simvastatin tab 10 mg .......................30 simvastatin tab 20 mg .......................30 simvastatin tab 40 mg .......................30 simvastatin tab 5 mg.........................30 simvastatin tab 80 mg .......................30 sirolimus tab 0.5 mg .........................84 SIROLIMUS TAB 1 MG .......................84 SIROLIMUS TAB 2 MG .......................84 SIRTURO TAB 100MG ........................11 SIVEXTRO INJ 200MG ........................ 7 SIVEXTRO TAB 200MG ....................... 7 sm antacid sus anti-gas .....................71 sm antacid/ sus antigas .....................71 sm anti-diar tab 2mg.........................71 sm antifungl cre 2% ..........................98 sm artificia sol tears ..........................92 SM CALAMINE LOT .......................... 102 sm fiber lax cap 0.52gm ....................75 sm fiber lax tab 500mg......................75 sm fiber pow 28.3% ..........................75 sm fiber pow 48.57% ........................76 sm fiber pow 58.6% ..........................76 sm first aid oin 500/gm .....................97 SM GLUCOSE CHW ORANGE ...............67 SM GLUCOSE CHW RASPBERY ............67 SM GLUCOSE CHW SOUR APP ............67 sm hydrocort cre 1% ...................... 101 sm laxative tab 5mg ec ..................... 76 sm micon 7 sup 100mg ..................... 79 sm milk magn sus mint ..................... 76 sm nicotine dis 14mg/24h ................. 58 sm nicotine dis 21mg ........................ 58 sm nicotine dis 7mg/24hr .................. 58 sm nicotine gum 2mg mint ................ 58 sm nicotine gum 4mg ....................... 58 sm nicotine gum 4mg mint ................ 58 sm nicotine loz 4mg mint .................. 58 sm povid-iod sol 10% ..................... 102 sm senna lax tab 8.6mg .................... 76 sm stomach sus 262/15ml ................ 71 sm triple oin antibiot ........................ 97 sodium bicarbonate tab 325 mg ......... 71 sodium bicarbonate tab 650 mg ......... 71 sodium chloride hypertonic ophth oint 5% ...................................................... 92 sodium chloride hypertonic ophth soln 5% ...................................................... 92 SODIUM CHLORIDE INJ 0.45% .......... 89 SODIUM CHLORIDE INJ 2.5 MEQ/ML (14.6%) .......................................... 86 SODIUM CHLORIDE INJ 3% ............... 89 SODIUM CHLORIDE INJ 5% ............... 89 SODIUM CHLORIDE IRRIGATION SOLN 0.9% ............................................ 102 SODIUM CHLORIDE IV SOLN 0.9% ..... 89 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN ............................... 87 sodium phenylbutyrate oral powder 3 gm/teaspoonful ................................ 65 sodium polystyrene sulfonate oral susp 15 gm/60ml ......................................... 61 SOLIA TAB ...................................... 64 SOLTAMOX SOL 10MG/5ML ............... 21 soluble fib pow therapy ..................... 76 SOLU-CORTEF INJ 250MG ................. 67 SOMATULINE INJ 120/.5ML ............... 68 SOMATULINE INJ 60/0.2ML ............... 68 SOMATULINE INJ 90/0.3ML ............... 68 SOMAVERT INJ 10MG ....................... 68 SOMAVERT INJ 15MG ....................... 68 SOMAVERT INJ 20MG ....................... 68 SOMAVERT INJ 25MG ....................... 68 SOMAVERT INJ 30MG ....................... 68 sorine tab 120mg ............................. 29 141 sorine tab 160mg..............................29 sorine tab 240mg..............................29 sorine tab 80mg ...............................29 sotalol hcl (afib/afl) tab 120 mg ..........29 sotalol hcl (afib/afl) tab 160 mg ..........29 sotalol hcl (afib/afl) tab 80 mg ...........29 sotalol hcl tab 120 mg .......................29 sotalol hcl tab 160 mg .......................29 sotalol hcl tab 240 mg .......................29 sotalol hcl tab 80 mg .........................29 SOVALDI TAB 400MG ........................12 SPIRIVA CAP HANDIHLR ....................93 SPIRIVA SPR RESPIMAT .....................93 spironolactone & hydrochlorothiazide tab 25-25 mg ........................................35 spironolactone tab 100 mg .................26 spironolactone tab 25 mg ..................26 spironolactone tab 50 mg ..................26 sprintec 28 tab 28 day .......................64 SPRYCEL TAB 100MG ........................22 SPRYCEL TAB 140MG ........................22 SPRYCEL TAB 20MG ..........................22 SPRYCEL TAB 50MG ..........................22 SPRYCEL TAB 70MG ..........................22 SPRYCEL TAB 80MG ..........................22 sps sus 15gm/60 ..............................61 SSD CRE 1% ....................................97 stavudine cap 15 mg .........................10 stavudine cap 20 mg .........................10 stavudine cap 30 mg .........................10 stavudine cap 40 mg .........................10 stavudine for oral soln 1 mg/ml ..........10 stim laxat tab 5mg ec ........................76 STIVARGA TAB 40MG ........................22 stomach relf chw 262mg ....................71 stomach relf sus 262/15ml .................71 stomach relf sus 525/15ml .................71 stool softnr cap 100mg ......................76 stool softnr cap 240mg ......................76 stool softnr cap 250mg ......................76 stool softnr tab 8.6-50mg ..................76 STRATTERA CAP 100MG ....................54 STRATTERA CAP 10MG ......................54 STRATTERA CAP 18MG ......................54 STRATTERA CAP 25MG ......................54 STRATTERA CAP 40MG ......................54 STRATTERA CAP 60MG ......................54 STRATTERA CAP 80MG ......................54 streptomycin sulfate for inj 1 gm.......... 5 STRIBILD TAB.................................. 10 SUBOXONE MIS 12-3MG ................... 58 SUBOXONE MIS 2-0.5MG .................. 58 SUBOXONE MIS 4-1MG ..................... 58 SUBOXONE MIS 8-2MG ..................... 58 SUCRAID SOL 8500/ML ..................... 76 sucralfate tab 1 gm .......................... 76 sulfacetamide sodium lotion 10% (acne) ...................................................... 97 sulfacetamide sodium ophth oint 10% 90 sulfacetamide sodium ophth soln 10% 90 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% ........................ 90 sulfadiazine tab 500mg ....................... 5 sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml.................................. 7 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml.................................. 7 sulfamethoxazole-trimethoprim tab 400-80 mg ........................................ 7 sulfamethoxazole-trimethoprim tab 800-160 mg ...................................... 7 SULFAMYLON CRE 85MG/GM ............. 97 sulfasalazine tab 500 mg................... 73 sulfazine ec tab 500mg ..................... 73 sulindac tab 150 mg ........................... 2 sulindac tab 200 mg ........................... 2 SUMATRIPTAN NASAL SPRAY 20 MG/ACT ...................................................... 55 SUMATRIPTAN NASAL SPRAY 5 MG/ACT ...................................................... 55 sumatriptan succinate inj 6 mg/0.5ml . 55 SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 4 MG/0.5ML ............ 55 sumatriptan succinate solution auto-injector 6 mg/0.5ml .................. 55 SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 4 MG/0.5ML ................... 55 SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 6 MG/0.5ML ................... 55 sumatriptan succinate solution prefilled syringe 6 mg/0.5ml .......................... 55 sumatriptan succinate tab 100 mg ..... 55 sumatriptan succinate tab 25 mg ....... 55 sumatriptan succinate tab 50 mg ....... 55 SUPRAX CAP 400MG ......................... 14 suprax chw 100mg ........................... 14 142 suprax chw 200mg............................14 suprax sus 100/5ml ..........................14 suprax sus 200/5ml ..........................14 SUPRAX SUS 500/5ML .......................14 SUPREP BOWEL SOL PREP .................76 surgilube gel .................................. 102 SURMONTIL CAP 100MG ....................47 SURMONTIL CAP 25MG ......................47 SURMONTIL CAP 50MG ......................47 SUSTIVA CAP 200MG ........................10 SUSTIVA CAP 50MG ..........................10 SUSTIVA TAB 600MG ........................10 SUTENT CAP 12.5MG .........................22 SUTENT CAP 25MG ...........................22 SUTENT CAP 37.5MG .........................22 SUTENT CAP 50MG ...........................22 syeda tab 3-0.03mg ..........................64 SYLATRON KIT 200MCG .....................23 SYLATRON KIT 300MCG .....................23 SYLATRON KIT 600MCG .....................23 SYMBICORT AER 160-4.5 ...................96 SYMBICORT AER 80-4.5.....................96 SYMLINPEN 60 INJ 1000MCG .............59 SYMLNPEN 120 INJ 1000MCG .............59 SYNAGIS INJ 100MG/ML ....................85 SYNAGIS INJ 50MG ...........................85 SYNAREL SOL 2MG/ML ......................64 SYNERCID INJ 500MG ........................ 7 SYNTHROID TAB 100MCG ..................69 SYNTHROID TAB 112MCG ..................69 SYNTHROID TAB 125MCG ..................69 SYNTHROID TAB 137MCG ..................69 SYNTHROID TAB 150MCG ..................69 SYNTHROID TAB 175MCG ..................69 SYNTHROID TAB 200MCG ..................69 SYNTHROID TAB 25MCG ....................69 SYNTHROID TAB 300MCG ..................69 SYNTHROID TAB 50MCG ....................69 SYNTHROID TAB 75MCG ....................69 SYNTHROID TAB 88MCG ....................69 SYPRINE CAP 250MG .........................61 SYSTANE PF SOL ..............................92 T TABLOID TAB 40MG ..........................19 tacrolimus cap 0.5 mg .......................84 tacrolimus cap 1 mg ..........................84 tacrolimus cap 5 mg ..........................85 TAFINLAR CAP 50MG .........................22 TAFINLAR CAP 75MG ........................ 22 TAMIFLU CAP 30MG .......................... 12 TAMIFLU CAP 45MG .......................... 12 TAMIFLU CAP 75MG .......................... 12 TAMIFLU SUS 6MG/ML ...................... 12 tamoxifen citrate tab 10 mg (base equivalent) ...................................... 21 tamoxifen citrate tab 20 mg (base equivalent) ...................................... 21 tamsulosin hcl cap 0.4 mg ................. 78 TARCEVA TAB 100MG ....................... 22 TARCEVA TAB 150MG ....................... 22 TARCEVA TAB 25MG ......................... 22 TARGRETIN CAP 75MG ...................... 23 TARGRETIN GEL 1% ....................... 102 TASIGNA CAP 150MG ....................... 22 TASIGNA CAP 200MG ....................... 22 tazicef inj 1gm ................................. 14 tazicef inj 2gm ................................. 14 tazicef inj 6gm ................................. 14 TAZORAC CRE 0.05% ....................... 99 TAZORAC CRE 0.1% ......................... 99 taztia xt cap 120mg/24 ..................... 34 taztia xt cap 180mg/24 ..................... 34 taztia xt cap 240mg/24 ..................... 34 taztia xt cap 300mg/24 ..................... 34 taztia xt cap 360mg/24 ..................... 34 tears natura sol ii op ......................... 92 tears pure sol .................................. 92 TEFLARO INJ 400MG ......................... 14 TEFLARO INJ 600MG ......................... 14 TEGRETOL SUS 100/5ML ................... 42 TEGRETOL TAB 200MG ..................... 42 TEGRETOL-XR TAB 100MG ................ 42 TEGRETOL-XR TAB 200MG ................ 42 TEGRETOL-XR TAB 400MG ................ 42 TEKAMLO TAB 150-10MG .................. 34 TEKAMLO TAB 150-5MG .................... 34 TEKTURNA HCT TAB 150-12.5 ........... 34 TEKTURNA HCT TAB 150-25MG .......... 34 TEKTURNA HCT TAB 300-12.5 ........... 34 TEKTURNA HCT TAB 300-25MG .......... 34 TEKTURNA TAB 150MG ..................... 34 TEKTURNA TAB 300MG ..................... 35 temazepam cap 15 mg ..................... 55 temazepam cap 7.5 mg .................... 55 TENIVAC INJ 5-2LF ........................... 85 terazosin hcl cap 1 mg ...................... 26 143 terazosin hcl cap 10 mg .....................26 terazosin hcl cap 2 mg.......................26 terazosin hcl cap 5 mg.......................26 terbinafine cre 1% ............................98 terbinafine hcl cream 1% ...................98 terbinafine hcl tab 250 mg .................. 8 terbutaline sulfate inj 1 mg/ml ...........94 terbutaline sulfate tab 2.5 mg ............94 terbutaline sulfate tab 5 mg ...............94 terconazole vaginal cream 0.4% .........79 terconazole vaginal cream 0.8% .........79 terconazole vaginal suppos 80 mg ......79 TESTIM GEL 1%(50MG) .....................58 testosterone cypionate im inj in oil 100 mg/ml .............................................58 testosterone cypionate im inj in oil 200 mg/ml .............................................59 testosterone enanthate im inj in oil 200 mg/ml .............................................59 TET/DIP TOX INJ 2-2 LF.....................85 TETANUS TOX INJ 5LF ADS ................86 TETRABENAZINE TAB 12.5 MG ...........56 TETRABENAZINE TAB 25 MG ..............56 TEV-TROPIN INJ 5MG ........................67 texacort sol 2.5% ........................... 101 THALOMID CAP 100MG ......................84 THALOMID CAP 150MG ......................84 THALOMID CAP 200MG ......................84 THALOMID CAP 50MG ........................84 theo-24 cap 100mg cr .......................96 theo-24 cap 200mg cr .......................96 theo-24 cap 300mg cr .......................96 theo-24 cap 400mg er .......................96 theophylline soln 80 mg/15ml ............96 theophylline tab sr 12hr 100 mg .........96 theophylline tab sr 12hr 200 mg .........96 theophylline tab sr 12hr 300 mg .........96 theophylline tab sr 12hr 450 mg .........96 theophylline tab sr 24hr 400 mg .........96 theophylline tab sr 24hr 600 mg .........96 thioridazine hcl tab 10 mg..................53 thioridazine hcl tab 100 mg ................53 thioridazine hcl tab 25 mg..................53 thioridazine hcl tab 50 mg..................53 thiothixene cap 1 mg .........................53 thiothixene cap 10 mg .......................53 thiothixene cap 2 mg .........................53 thiothixene cap 5 mg .........................53 thrive gum 2mg mint ........................ 58 thrive gum 4mg mint ........................ 58 tiagabine hcl tab 2 mg ...................... 42 tiagabine hcl tab 4 mg ...................... 42 TIKOSYN CAP 125MCG ...................... 29 TIKOSYN CAP 250MCG ...................... 29 TIKOSYN CAP 500MCG ...................... 29 TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25%.................................... 92 TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.5% ..................................... 92 timolol maleate ophth soln 0.25% ...... 92 timolol maleate ophth soln 0.5% ........ 92 timolol maleate tab 10 mg ................ 32 timolol maleate tab 20 mg ................ 32 timolol maleate tab 5 mg .................. 32 tioconazole oin 6.5% vag .................. 79 TIVICAY TAB 50MG........................... 10 tizanidine hcl tab 2 mg (base equivalent) ...................................................... 57 tizanidine hcl tab 4 mg (base equivalent) ...................................................... 57 tobra/nacl inj 80/0.9 .......................... 5 TOBRADEX OIN 0.3-0.1% ................. 90 TOBRADEX ST SUS 0.3-0.05.............. 90 tobramycin nebu soln 300 mg/5ml ....... 5 tobramycin ophth soln 0.3% .............. 90 tobramycin sulfate for inj 1.2 gm ......... 5 tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) ............................................. 5 tobramycin sulfate inj 10 mg/ml .......... 6 tobramycin sulfate inj 2 gm/50ml (40 mg/ml) ............................................. 5 tobramycin sulfate inj 80 mg/2ml (40 mg/ml) ............................................. 6 tobramycin-dexamethasone ophth susp 0.3-0.1% ........................................ 90 TOBREX OIN 0.3% OP ...................... 90 TOLTERODINE TARTRATE CAP SR 24HR 2 MG ................................................. 78 TOLTERODINE TARTRATE CAP SR 24HR 4 MG ................................................. 78 tolterodine tartrate tab 1 mg ............. 78 tolterodine tartrate tab 2 mg ............. 78 topiramate sprinkle cap 15 mg ........... 42 topiramate sprinkle cap 25 mg ........... 42 topiramate tab 100 mg ..................... 42 topiramate tab 200 mg ..................... 42 144 topiramate tab 25 mg........................42 topiramate tab 50 mg........................42 toposar inj 1gm/50ml ........................24 topotecan hcl for inj 4 mg ..................24 torsemide inj 20mg/2ml ....................35 torsemide inj 50mg/5ml ....................35 torsemide tab 10 mg .........................36 torsemide tab 100 mg .......................36 torsemide tab 20 mg .........................36 torsemide tab 5 mg ...........................36 total fiber pow ..................................76 TOUJEO SOLO INJ 300IU/ML ..............59 TOVIAZ TAB 4MG ..............................78 TOVIAZ TAB 8MG ..............................78 TPN ELECTROL INJ ............................87 TRACLEER TAB 125MG ......................37 TRACLEER TAB 62.5MG .....................37 TRADJENTA TAB 5MG ........................60 tramadol hcl tab 50 mg ...................... 2 tramadol-acetaminophen tab 37.5-325 mg ................................................... 2 trandolapril tab 1 mg.........................26 trandolapril tab 2 mg.........................26 trandolapril tab 4 mg.........................26 tranexamic acid inj 100 mg/ml ...........81 tranexamic acid tab 650 mg ...............81 TRANSDERM-SC DIS 1MG ..................72 tranylcypromine sulfate tab 10 mg ......47 travasol inj 10% ...............................87 TRAVATAN Z DRO 0.004% .................92 travel sick chw 25mg.........................72 trazodone hcl tab 100 mg ..................47 trazodone hcl tab 150 mg ..................47 trazodone hcl tab 50 mg ....................47 TREANDA INJ 100MG ........................18 TREANDA INJ 180/2ML ......................18 TREANDA INJ 25MG ..........................18 TREANDA INJ 45/0.5ML .....................18 TRECATOR TAB 250MG ......................11 TRELSTAR MIX INJ 11.25MG ..............21 TRELSTAR MIX INJ 3.75MG ................21 tretinoin cap 10 mg ...........................23 tretinoin cream 0.025% .....................97 tretinoin cream 0.05%.......................97 tretinoin cream 0.1% ........................97 tretinoin gel 0.01% ...........................97 tretinoin gel 0.025% .........................97 triamcinolone acetonide cream 0.025% .................................................... 101 triamcinolone acetonide cream 0.1% 101 triamcinolone acetonide cream 0.5% 101 triamcinolone acetonide dental paste 0.1% ............................................ 103 triamcinolone acetonide lotion 0.025% .................................................... 101 triamcinolone acetonide lotion 0.1% . 101 triamcinolone acetonide oint 0.025% 101 triamcinolone acetonide oint 0.1% ... 101 triamcinolone acetonide oint 0.5% ... 101 triamterene & hydrochlorothiazide cap 37.5-25 mg ..................................... 36 triamterene & hydrochlorothiazide tab 37.5-25 mg ..................................... 36 triamterene & hydrochlorothiazide tab 75-50 mg ........................................ 36 TRIBENZOR20- TAB 5-12.5MG ........... 27 TRIBENZOR40- TAB 10-12.5.............. 27 TRIBENZOR40- TAB 10-25MG ............ 27 TRIBENZOR40- TAB 5-12.5MG ........... 27 TRIBENZOR40- TAB 5-25MG .............. 27 triderm cre 0.1% ........................... 101 trifluoperazine hcl tab 1 mg ............... 53 trifluoperazine hcl tab 10 mg ............. 53 trifluoperazine hcl tab 2 mg ............... 53 trifluoperazine hcl tab 5 mg ............... 53 trifluridine ophth soln 1% .................. 90 trihexyphenidyl hcl elixir 0.4 mg/ml .... 49 trihexyphenidyl hcl tab 2 mg ............. 49 trihexyphenidyl hcl tab 5 mg ............. 49 tri-legest tab fe ................................ 64 trilyte sol ........................................ 76 trimethoprim tab 100 mg .................... 7 TRINESSA TAB ................................. 64 triple antib oin ................................. 97 triple antib oin max st ....................... 97 triple antib oin plus .......................... 97 tri-previfem tab ............................... 64 TRISENOX SOL 10MG/10M ................ 23 tri-sprintec tab ................................. 64 TRIUMEQ TAB .................................. 10 trivora-28 tab .................................. 64 TRIXAICIN CRE 0.025% .................. 102 trixaicin hp cre 0.075% ................... 102 TROPHAMINE INJ 10% ...................... 87 trospium chloride tab 20 mg .............. 78 TRUE METRIX KIT METER ................ 103 145 TRUE METRIX TES ........................... 103 TRUERESULT KIT SYSTEM ................ 103 TRUETEST TES ............................... 103 TRULICITY INJ 0.75/0.5 .....................59 TRULICITY INJ 1.5/0.5 ......................59 TRUMENBA INJ .................................86 TRUVADA TAB 200-300 .....................11 TUDORZA PRES AER 400/ACT ............93 TWINRIX INJ ....................................86 TYBOST TAB 150MG ..........................10 TYGACIL INJ 50MG............................. 7 TYKERB TAB 250MG ..........................22 TYPHIM VI INJ ..................................86 TYSABRI INJ 300/15ML......................56 TYZEKA TAB 600MG ..........................12 U UCERIS TAB 9MG ..............................73 ULORIC TAB 40MG ............................. 1 ULORIC TAB 80MG ............................. 1 UNITHROID TAB 100MCG ..................69 UNITHROID TAB 112MCG ..................69 UNITHROID TAB 125MCG ..................69 UNITHROID TAB 150MCG ..................70 UNITHROID TAB 175MCG ..................70 UNITHROID TAB 200MCG ..................70 UNITHROID TAB 25MCG ....................69 UNITHROID TAB 300MCG ..................70 UNITHROID TAB 50MCG ....................69 UNITHROID TAB 75MCG ....................69 UNITHROID TAB 88MCG ....................69 ursodiol cap 300 mg ..........................76 ursodiol tab 250 mg ..........................76 ursodiol tab 500 mg ..........................76 V VAGIFEM TAB 10MCG ........................65 valacyclovir hcl tab 1 gm ...................12 valacyclovir hcl tab 500 mg ................12 VALCHLOR GEL 0.016% ................... 102 VALCYTE SOL 50MG/ML .....................12 valganciclovir hcl tab 450 mg (base equivalent) ......................................12 valproate sodium inj 100 mg/ml .........42 valproate sodium syrup 250 mg/5ml (base equiv) .....................................42 valproic acid cap 250 mg ...................42 valsartan tab 160 mg ........................28 valsartan tab 320 mg ........................28 valsartan tab 40 mg ..........................28 valsartan tab 80 mg ......................... 28 valsartan-hydrochlorothiazide tab 160-12.5 mg ................................... 27 valsartan-hydrochlorothiazide tab 160-25 mg ................................................. 27 valsartan-hydrochlorothiazide tab 320-12.5 mg ................................... 28 valsartan-hydrochlorothiazide tab 320-25 mg ................................................. 28 valsartan-hydrochlorothiazide tab 80-12.5 mg ..................................... 27 vancomycin hcl cap 125 mg................. 7 vancomycin hcl cap 250 mg................. 7 vancomycin hcl for inj 10 gm ............... 7 vancomycin hcl for inj 1000 mg ........... 7 vancomycin hcl for inj 500 mg ............. 7 vancomycin hcl for inj 5000 mg ........... 7 vancomycin inj 750mg ........................ 7 VANDAZOLE GEL 0.75% ................... 79 VAQTA INJ 25/0.5ML ........................ 86 VAQTA INJ 50UNT/ML ....................... 86 VARIVAX INJ ................................... 86 VASCEPA CAP 1GM ........................... 30 VELCADE INJ 3.5MG ......................... 20 velivet pak ...................................... 64 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) ...................................... 47 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) ...................................... 47 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) ...................................... 47 venlafaxine hcl tab 100 mg ............... 47 venlafaxine hcl tab 25 mg ................. 47 venlafaxine hcl tab 37.5 mg .............. 47 venlafaxine hcl tab 50 mg ................. 47 venlafaxine hcl tab 75 mg ................. 47 verapamil hcl cap sr 24hr 100 mg ...... 34 verapamil hcl cap sr 24hr 120 mg ...... 34 verapamil hcl cap sr 24hr 180 mg ...... 34 verapamil hcl cap sr 24hr 200 mg ...... 34 verapamil hcl cap sr 24hr 240 mg ...... 34 verapamil hcl cap sr 24hr 300 mg ...... 34 VERAPAMIL HCL CAP SR 24HR 360 MG 34 verapamil hcl iv soln 2.5 mg/ml ......... 34 verapamil hcl tab 120 mg .................. 34 verapamil hcl tab 40 mg ................... 34 verapamil hcl tab 80 mg ................... 34 verapamil hcl tab cr 120 mg .............. 34 146 verapamil hcl tab cr 180 mg ...............34 verapamil hcl tab cr 240 mg ...............34 VERSACLOZ SUS 50MG/ML ................53 VESICARE TAB 10MG ........................78 VESICARE TAB 5MG ..........................78 VIBRAMYCIN SYP 50MG/5ML ..............18 VICTOZA INJ 18MG/3ML ....................59 VICTRELIS CAP 200MG ......................12 VIDEX SOL 2GM ...............................10 VIDEX SOL 4GM ...............................10 VIGAMOX DRO 0.5% .........................90 VIIBRYD KIT ....................................47 VIIBRYD KIT STARTER .......................47 VIIBRYD TAB 10MG ...........................47 VIIBRYD TAB 20MG ...........................47 VIIBRYD TAB 40MG ...........................47 VIMPAT INJ 200MG/20 ......................42 VIMPAT SOL 10MG/ML .......................42 VIMPAT TAB 100MG ..........................42 VIMPAT TAB 150MG ..........................42 VIMPAT TAB 200MG ..........................42 VIMPAT TAB 50MG ............................42 vinblastine inj 1mg/ml .......................20 vincasar pfs inj 1mg/ml .....................20 vincristine sulfate iv soln 1 mg/ml .......20 vinorelbine tartrate inj 10 mg/ml (base equiv) .............................................20 vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv) .........................20 viorele tab .......................................64 VIRACEPT TAB 250MG .......................10 VIRACEPT TAB 625MG .......................10 VIRAMUNE XR TAB 100MG .................10 VIREAD POW 40MG/GM .....................10 VIREAD TAB 150MG ..........................10 VIREAD TAB 200MG ..........................10 VIREAD TAB 250MG ..........................10 VIREAD TAB 300MG ..........................10 vitamins a & d oint .......................... 102 VITEKTA TAB 150MG .........................10 VITEKTA TAB 85MG ...........................10 VOLTAREN GEL 1% ......................... 102 voriconazole for inj 200 mg ................. 8 voriconazole for susp 40 mg/ml ........... 8 voriconazole tab 200 mg ..................... 8 voriconazole tab 50 mg ...................... 8 VOTRIENT TAB 200MG ......................22 vyfemla tab 0.4-35 ...........................64 W warfarin sodium tab 1 mg ................. 80 warfarin sodium tab 10 mg ................ 80 warfarin sodium tab 2 mg ................. 80 warfarin sodium tab 2.5 mg ............... 80 warfarin sodium tab 3 mg ................. 80 warfarin sodium tab 4 mg ................. 80 warfarin sodium tab 5 mg ................. 80 warfarin sodium tab 6 mg ................. 80 warfarin sodium tab 7.5 mg ............... 80 WATER FOR IRRIGATION, STERILE IRRIGATION SOLN ......................... 103 WELCHOL PAK 3.75GM ..................... 30 WELCHOL TAB 625MG ...................... 30 X XALKORI CAP 200MG ........................ 22 XALKORI CAP 250MG ........................ 22 XARELTO STAR TAB 15/20MG ............ 80 XARELTO TAB 10MG ......................... 80 XARELTO TAB 15MG ......................... 80 XARELTO TAB 20MG ......................... 80 XENAZINE TAB 12.5MG ..................... 56 XENAZINE TAB 25MG ....................... 56 XGEVA INJ ...................................... 68 XIFAXAN TAB 550MG ........................ 76 XIGDUO XR TAB 10-1000 .................. 60 XIGDUO XR TAB 10-500MG ............... 60 XIGDUO XR TAB 5-1000MG ............... 60 XIGDUO XR TAB 5-500MG ................. 60 XOLAIR SOL 150MG ......................... 95 XOPENEX HFA AER ........................... 94 XTANDI CAP 40MG ........................... 21 XYREM SOL 500MG/ML ..................... 57 Y YF-VAX INJ ...................................... 86 Z zafirlukast tab 10 mg ........................ 94 zafirlukast tab 20 mg ........................ 94 zarah tab 3-0.03mg.......................... 64 ZAVESCA CAP 100MG ....................... 65 zazole cre 0.4% ............................... 79 ZAZOLE CRE 0.8% ........................... 79 zeasorb-af pow 2% .......................... 98 ZELBORAF TAB 240MG...................... 22 ZEMAIRA INJ 1000MG ....................... 95 zenatane cap 10mg .......................... 97 zenatane cap 20mg .......................... 97 zenatane cap 30mg .......................... 97 147 zenatane cap 40mg ...........................97 zenchent tab ....................................64 ZENPEP CAP 10000UNT .....................77 ZENPEP CAP 15000UNT .....................77 ZENPEP CAP 20000UNT .....................77 ZENPEP CAP 25000UNT .....................77 ZENPEP CAP 3000UNIT ......................77 ZENPEP CAP 40000UNT .....................77 ZENPEP CAP 5000UNIT ......................77 ZETIA TAB 10MG ..............................30 ZIAGEN SOL 20MG/ML ......................10 zidovudine cap 100 mg ......................10 zidovudine syrup 10 mg/ml ................10 zidovudine tab 300 mg ......................10 zinc oxide oin 20% .......................... 102 zinc oxide oint 20%......................... 102 ziprasidone hcl cap 20 mg ..................53 ziprasidone hcl cap 40 mg ..................53 ziprasidone hcl cap 60 mg ..................53 ziprasidone hcl cap 80 mg ..................53 ZMAX SUS 2GM ................................15 zoledronic acid inj conc for iv infusion 4 mg/5ml ...........................................61 ZOLINZA CAP 100MG ........................20 zolmitriptan orally disintegrating tab 2.5 mg ..................................................56 zolmitriptan orally disintegrating tab 5 mg ...................................................... 56 zolmitriptan tab 2.5 mg .................... 56 zolmitriptan tab 5 mg ....................... 56 zolpidem tartrate tab 10 mg .............. 55 zolpidem tartrate tab 5 mg ................ 55 ZOMETA INJ 4MG/100 ...................... 61 zonisamide cap 100 mg .................... 43 zonisamide cap 25 mg ...................... 43 zonisamide cap 50 mg ...................... 43 ZONTIVITY TAB 2.08MG .................... 82 ZORTRESS TAB 0.25MG .................... 85 ZORTRESS TAB 0.5MG ...................... 85 ZORTRESS TAB 0.75MG .................... 85 ZOSTAVAX INJ ................................. 86 ZYDELIG TAB 100MG ........................ 22 ZYDELIG TAB 150MG ........................ 22 ZYKADIA CAP 150MG ........................ 22 ZYLET SUS 0.5-0.3% ........................ 90 ZYPREXA RELP INJ 210MG................. 53 ZYPREXA RELP INJ 300MG................. 53 ZYPREXA RELP INJ 405MG................. 53 ZYTIGA TAB 250MG .......................... 21 ZYVOX SUS 100MG/5M ....................... 7 ZYVOX TAB 600MG ............................. 7 148 Version 14 UPDATED: 11/2015 Member Services (877) 901-8181, TTY/TDD 711 Monday - Friday, 8 a.m. - 8 p.m. local time 44088MMP1115
Similar documents
Comprehensive Formulary
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., REPLAX) and generic drugs are listed in lower-case italics (e.g., ibuprofen). The information in the requi...
More informationFormulary - MetroPlus Health Plan
MetroPlus Health Plan’s Drug List The drug list set forth below gives information about the drugs covered by MetroPlus Health Plan. The first column of the chart lists the drug name. Brand-name dru...
More informationMolina Washington Marketplace 1/1/16
Requirements/Limits MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL PA; MAIL PA; MAIL PA; MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL MAIL PA; MAIL PA; MAIL PA...
More informationCareSource MyCare Ohio (Medicare
pages 1-144. You can also get more information by visiting our web site at CareSource.com/MyCare. We have posted online documents that explain our prior authorization and step therapy restrictions....
More information2015 Florida - Molina Healthcare
ANTIANXIETY AGENTS Antianxiety Agents - Misc. buspirone tab 5mg buspirone tab 7.5mg buspirone tab 10mg buspirone tab 15mg hydroxyz hcl syp 10mg/5ml hydroxyz hcl tab 10mg hydroxyz hcl tab 25mg hydro...
More information